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Distance Learning Lesson Request Form

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Primary Contact Person
Name:
Title:
Phone:
E-mail:
Technology Contact Person Check if same as above
Name:
Title:
Phone:
E-mail:
School/Institution
Name:
Street:
City:
State:
Zip:
Billing Information Check if same as above
Name:
Institution:
Address:
City:
State:
Zip:
Class & Lesson Information
Lesson:
# of Students:
Grade Level:
Teacher Name:
Class Subject:
  Tell us about your class!
How will this lesson relate to your curriculum? Any information you provide will help us to relate this lesson more directly to your studies.
Lesson Date and Time
(Up to 60 minutes per class Monday through Friday between 8:00 a.m. and 4:00 p.m. Eastern Time. If you use a bridging service, please add 10 extra minutes to your scheduled lesson time in case there's a starting delay.)
1st Choice:
Date:
Start:
End:
2nd Choice:
Date:
Start:
End:
Test Call Date and Time
(Monday through Friday between 10:00 a.m. and 4:00 p.m. Eastern Time. We suggest scheduling a test call approximately one week prior)
1st Choice:
Date:
Time:
2nd Choice:
Date:
Time:
Videoconferencing Equipment Information
Manufacturer:
Model:
Connection:
IP Address:
Bandwidth: 384 kbps Other kbps
Code: Please enter the following code into the text field in order to validate this message.
 

If you would like to submit multiple lesson requests, use the "Submit & Duplicate" button to pre-populate your next request.

For more information, please contact The Division of Education by phone at (215) 684-7580, by fax at (215) 236-4063, or by e-mail at .

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