Name:

School /Agency:

Position at School:

Phone Number:

Email Address:

City:

State:

Today's Date:

/ / (Month, Day, Year)

*How did you hear about CLIMB?

What time of the school year are you interested in having us perform?
Fall Spring Not Sure

What grade levels are at your school?

We visit classes of no more than 35 students at a time. How many classes do you anticipate we’ll be visiting?

I don't know

With standard classes, we typically only visit each classroom once. Are you interested in multiple visits?
Yes No

Are you interested in CLIMB conducting a parent event	(What is this?)
Yes No

Are you interested in having CLIMB conduct an inservice?	(What is this?)
Yes No

Are you interested in a set-up meeting?	(What is this?)
Yes No

Are more than 25% of your students English Language Learners?
Yes No

If yes, do they have an in-class interpreter who could work with our Actors?
Yes No

Will we be visiting any self-contained classes of students with special needs?
Yes No

What time does your school start in the morning?

Can you ensure that a member of your school staff will be in the classroom with our actors at all times?
Yes No

Is there any special place we should park when we get to your school?

When, generally, is the best time of day for us to call you?

Would you be the main contact?
Yes No

Write in name and contact info of main contact if "No."

PROMOTIONAL CODE: (optional)

When finished, click the Submit button below to send your form to CLIMB’s Outreach Department.