Contact Us Form

*Denotes Required Field

*Date of Request:

Please allow a minimum of three weeks between the time you submit your request and the date when services are needed.

*First Name:

*Last Name:

*E-mail:

*School:

*Telephone:

I would like assistance in the following areas:

*Subject(s):

Topic (if applicable):

*Grade Level:

*Date(s) Needed:

*Number of Students:

*Time Frame of Activity:

Indicate the type of assistance needed (please choose at least one of the following):
Tutoring
One-on-One Assistance
Lab Assistant
Serve as a Substitute Teacher
Assist with Illustrations/Experiments in the Classroom (please enter topic in comments box below)
Assist Students in Preparing for Academic Competition(s) (please specify in comments box below)
Assist Students in Preparing for the Gateway/End-of-Course Exams
Assist with Special Event (please specify in comments box below)
Counsel Students on Colleges/Majors/Scholarship Opportunities
Counsel Students on Workforce Issues
Surplus
Science Fair Judge
Make a Classroom Presentation

Presentation Topic:

Purpose of Presentation:

Presentation Location:

IndoorOutdoor

If Outdoor - Electricity Available?:

YesNo

Other (please specify in box below)

Other:

Comments: