Outreach Form

Print this form and ask your teacher to fill it out and send it to the Commission or have your teacher contact the Commission directly at 1 866 374-3617 toll-free or at
860 566-5682.

Contact Teacher:_________________ Telephone number:_________________

Class:________________

Grade:________________ Number of students:_____ Reading level:____________

School Name:_______________________________________

School Address:_____________________________________

Date(s) you would like to have workshop:___________________________

Length of class period:_________________

Recommendation/ preferred method of instruction (lecture, slides, etc.):__________________________________

___________________________________________________________________________________________

____________________________________________________________________________________________

Other comments:______________________________________________________________________________

____________________________________________________________________________________________