Please fill out the following form completely to assist us in processing your request:

 

First Name:	* Indicates Field is required.
Last Name:	*
Position:
Phone Number:	*
Email:	*
School Name:	*
School Street Address:
School City:	*
School Zip Code:
School Type:	Public      Charter       Private
School District (if applicable):
In which legislative district is your school located? To identify its district, please go to the link at right and type in your school’s address: Find District   (View Link) http://159.87.126.6/mapping/default2.asp?tname=Original.2004.Legislative.Map&org 2004leg=on&service=ircmaps&init=true
Please answer the following questions about your desired school visit:
What is the grade level of the students you are wanting your legislator to meet with?
How many classes are you wanting your legislator to visit ?
How many students per class ?
What are the desired date(s) for the visit (please be as specific is possible; for instance, it helps to give a range of dates that work for you, and/or a particular day of the week, as well as the time of day)? (The Program runs from the third week in September until November.)
Have you participated in the Legislators Back to School Program in the past? Yes   No
If so, which legislator(s) visited your classroom?