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2. Name*
3. Email Address*
5. School/Organization Name*
6. Phone Number*
8. Program Requested*
   -- Select One --Colonial LifeColonial GamesPiratesCivil WarAfrican Americans in the Civil WarNative OnslowEuropean ContactDig It!Ocean LifePlant It!Weather Wonders!

   Please select the program you would like to have at your school.

9. 1st Preferred Date/Time*
   1st Preferred Date/Time

   1st Preferred Date/Time
   Please choose your first choice of Date and Time.
10. 2nd Preferred Date/Time *
    2nd Preferred Date/Time

    2nd Preferred Date/Time
    In the event that your first choice is unavailable please choose a second Date and Time
12. Grade

    1. PreK
    2. K
    3. 1
    4. 2
    5. 3
    6. 4
    7. 5
    8. 6
    9. 7
    10. 8
    11. 9
    12. 10
    13. 11
    14. 12

    Please select the grade/grades for which the program will be held.
13. Number of Classes*
    Please enter the total number of classes you would like to participate in the program.
14. Number of Students*
    Please enter the total number of students in all classes.
15. Students per Class*
    Please enter the average number of students in each class.
17. Additional Notes
    Please provide us with any additional information regarding your classes, needs, or special requests relating to the program.
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19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit Submit and Print

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