Program-RequestForm

History’s Alive! Program Request Form

Please complete the following form and e-mail to: sheilaarnold39@aol.com. Request form must be received 2 months in advance of first choice program date.

Contact Person’s Name & Title: ___________________________________________________________

Contact Person’s Phone Number: _________________________________________________________

Alternate Phone Number: ________________________________________________________

Organization/School Name: ______________________________________________________________

Organization/School Address: ____________________________________________________________

_____________________________________________________________________________________

Organization/School Phone Number: ______________________________________________________

Organization/School Fax Number: _________________________________________________________

Program(s) requested and grade(s) requested for (see program descriptions below):

A) ______________________________________________________________________________

B) ______________________________________________________________________________

Note: If you are interested in having a program developed around a particular them, please contact me by e-mail first. Also, Historic Character Presentations are most appropriate for grades 4 and Above.

Educational Institutions ONLY: If your program is scheduled for a Monday, Tuesday or Thursday, your school will be eligible to receive a FREE Evening Program for Parents. Would your school be interested in this Free Parent Program? Yes No

If yes, would you like:

________ Words of Excitement (see program description below), OR

________ A history-focused program. (This program uses the Historic Character Presentation along with Q&A and out of character presentation skills to emphasize the importance of the study of history in our education system today. It is a fun and interactive program for parents and kids.)

Presentation Date Request. Please put down a first and second choice.:

___________________________

Tentative Presentation Time (s).

__________________ AM/PM

Note: Unless otherwise specified, the programming costs covers 2 one-hour programs or two “class periods”. If you would like extended time, please list on the side of “tentative presentation times” and be prepared for an additional cost.

Audience Information (Schools do not answer the below two questions)

Expected Number of Program Attendees: __________

Age Group: _________

Payment method (note: A travel advance deposit of at least 25% is due one month prior to programming date. The balance is due directly to me on the date of the program.)

Check ____ Money Order ____ Credit Card ____

If credit card, what type? __________________________

Credit card information will be received using ProPay, a secure online website.

Presentation location

Where will the program be held?

Classroom _______ Gymnasium*________ Stage ________ Cafeteria ___________

Multipurpose room: __________ Church (altar area) __________ Meeting Room ______

Equipment requirements:

A microphone system (prefer a laveller microphone, but will use what is available)

An adult-sized chair (not rolling or rocking)

A bottle of water per each hour of presentation

Additional needs (added by Performer): _________________________________________

Can you provide the above equipment needs? Yes No

If not, or partially, please explain.

___________________________________________________________________________________

Questions/Comments:

___________________________________________________________________________________

Please complete the following form and e-mail to: sheilaarnold39@aol.com.