Virtual Group Program Scheduling Request

Name of Group Leader or Teacher *

Email Address *

Phone Number *

School/Organization Name *

School/Organization Type

If Other

School Street Address *

City *

State *

County (If North Carolina)

Zip / Post Code *

Grade level(s) of students *

Number of Classes *

Number of students per class *

Do you have students requiring accommodations, such as live captioning or ASL Interpreters?

If yes, please elaborate

Select your program topic below * Help Text

1st Date Choice *

2nd Date Choice *

3rd Date Choice *

Which time slot(s) would your group be available? (choose all that apply) *

Which Video Conferencing Tool(s) can you use? *

If you selected Other, please list:

Additional information, questions or comments