*Contact Name:
*School District:
*School Name:
*Mailing Address:
*School Phone Number:
Contact Mobile/Phone Number:
*Contact Email Address:
*Grade Level:
*Number of Classes:

Individually or in Pairs:

Each program is 45 minutes in length please note if you would prefer these programs individually or in pairs.

Individually Pairs 
*Total Number of Students:
*Program requested:

Date Range of Interest:

Day/Time Preference:

If certain Days and Times are preferred please note it here:

Special Considerations:

Please inform us of any medical or physical restrictions that we'll need to be aware of: (ie. Students in wheel chairs, hearing impaired – with microphone or sign language interpreter etc, sight impaired, autistic, needing special attention of some kind)

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