Videoconference Request Form THIS MUST BE RECEIVED TWO WEEKS PRIOR TO YOUR EVENT

In order to use this form your district must be enrolled in Model Schools. If you are not sure if you are in Model Schools please contact your site administrator.

School Information

Teacher's Last Name Teacher's First Name School's Name Location Model Schools Cooridinator Teacher's Phone # Teacher's E-mail Technical Contact at School Technical Contact's Phone # Phone # in Video Conference Room Grade Level of Students # of Classes Participating # of Students Participating Subject (if above elementary) IP address of Videoconferencing Unit  OR  the ISDN# What is the educational goal of your participation in the program (lesson objective)? What specific points/issues/facts do you want covered in the presentation? What would you like your students to visually see in the presentation? What support materials would you like, if any? Will this presentation be used to introduce, continue, or conclude your study of this topic?

Video Conference Information

Your Email Name of the videoconference you are requesting Name of Content Provider Contact Person at Content Provider Phone of Content Provider Address of Content Provider Fax of Content Provier Email of Content Provider Date of Videoconference Program Time of Program Alternate Date Alternate Time Additional Notes Estimated Expense Would you like this session recorded if possible?