FROM:

Contact Person:
High School:
H.S. Address:
Home Address:
Email Address:
Phone No. 1:
Phone No. 2:
Best time/no. to contact:

I would like to request that a Visiting Lecturer make a visit to our school.

Preferred dates:

First:
Second:
Third:

Level of student audience:

Approx. number of students:

Titles and Speakers:

List the titles and the speakers you desire. In requesting a topic and lecturer, please try to select a volunteer who lives within 50 miles of your school. If you leave this section blank, we will try to find a suitable lecturer for you. Please understand that we cannot promise to provide a lecturer on your list of choices in all cases.

First choice:
Second choice:
Third choice:
Fourth choice: