Virtual Program Request (Educator)

School Name*

Main Contact*

Phone Number*

School Email Address*

Total Number of Students*

Number of Classroom Learners*

Number of Remote Learners*

Grade Level*

Program Requested*

Program Date Requested*

Subject to availability. Request must be made at least two weeks in advance.

Program Time Requested (ET Eastern Time Zone)*

Subject to availability. Program start time can be between 10:00 a.m.-4:00 p.m. ET.

AM/PM Option

Program Fees - Per Program
Number of Students	Virtual Program Fee
1–30	$75
31–60	$90
61–90	$105
91–120	$120

Please complete the information below for our records. Payment will be required prior to participating in the program. Member schools and IPS schools will not be billed.

School District/Corp.*

County*

Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code

Billing Phone Number

Discount Code

Mailing Address (if different from billing address)

Street Address

Street Address Line 2

CityState

Zip Code

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