Name of videoconference program you are requesting:

_______________________________________________________________________

Date of program: _______________ Time of program: _______________

Alternate date: _________________ Alternate time: ________________

Teacher's Name: _________________________________________________________

School Name: ____________________________________________________________

Teacher's Phone #: ______________ Teacher's Email: ____________________________

Technical Contact at School: ____________________________
Phone: ____________________________

Phone in videoconference room: ____________________________
Grade level of students: ____________________________

Subject (if above elementary):____________________________
# of classes participating: ____________________________
# of students: ____________________________

IP address of codec (videoconferencing unit)_________________________ OR

ISDN # of codec________________________________________