Humane Education Program Request Form

Name of Group Requesting Program
(School, Civic/Business Org., Faith Community, etc.)
Troop #

(if Girl/Boy Scouts)
Address
Address 2
City
State
Zip
Total number of people in group
Number of Adults
Age Range
to
Grade
Contact Name (required)
Email (required)
Best Phone Number (required)
Please specify the type of request and preferred date and time by completing the information below.
Address if different from above:
(only required if you selected, "This request is for a PROGRAM at your location."
Address
Address 2
City
State
Zip
 
Requested program date:

(at least 4 weeks from today’s date):
Day of week:
Preferred Time:
Would you like the presentation to include a visiting animal?
(Please be sure animals are permitted at the location of the program)
Please indicate what service project you plan to do, and whether it will be completed before or after your program:
Please describe any special needs of the group members, or any special accommodations for this group that may affect the program or presentation.