Gabrielle Portrait – Small Print Version_

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Contact Information

Name*

First Last

Email*

Phone*

School Information

School*

School's Address*

Affiliation to School*

Classroom Grade Level*

# of Students in Class*

Type of Class*

Please give us a little more information about your class and if it's special day, bilingual, after-school, etc.

How would you like our officer to join your classroom?*

Virtual Platform

Please let us know what virtual platform you are currently using for your class if the request is to join virtually.

Virtual Login Info

Please let us know the Meeting ID and Password if request is to join virtually.

Availability

Please list your top 3 available days in order of preference.

First Choice*

Second Choice*

Third Choice*

Time Availability*

Please provide us some info on the best time for an officer to join your class for Storytime and we will do our best to work with your class schedule.

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Friday Availability*

1st Choice

2nd Choice

3rd Choice

Please list your top 3 available Fridays in order of preference.

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Classroom Grade Level*

I am the...(Required)

Student

Parent/Guardian

Student Name(Required)

First Last

Program Interest(Required)

WE CAN (6th-8th grades)

TUTORING (Middle & High School)

MAKING CHANGES (High School)

Student Email Address(Required)

Student Phone Number(Required)

School Name(Required)

Grade Level(Required)

Parent/Guardian Name(Required)

First Last

Parent/Guardian Email Address(Required)

Parent/Guardian Phone Number(Required)

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Name*
First Last
Email*
Phone*
School*
Address*
Street Address City State ZIP Code
Grade*
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Name*
First Last
Email*
Phone*
School*
Address*
Street Address City State ZIP Code
Grade*
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