Laurel House Educator Request Form

Educator Request Form

We offer free, interactive prevention programs for your students.

MIDDLE SCHOOL

HIGH SCHOOL

COLLEGE

* First name

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* Last name

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* Email

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* Teacher's Email Address

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* Job title

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* Phone number

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* Preferred method of contact:

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Best time to reach you by phone?

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* School/Organization Name

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*School/Org Address (Street, City, Zip)

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* What programs? (See guide above):

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Specify other program needs here:

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Any specific goals or topics to cover?

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* Have you booked Laurel House programs before?

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If yes, looking for the same program?

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* How many classes/sections?

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* How long are your class periods in MINUTES?

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* How many students will we be visiting TOTAL?

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* What GRADE(S) are your students in?

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Dates/Times (Ex: 09/23: 9am-10am)

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* Are you flexible if your time is booked?

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Other scheduling notes (e.g. Spanish)?

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Laurel House | P.O. Box 764 | Norristown, PA 19404 US

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