DC Arts and Humanities Education Collaborative


Request for Glow-box Shadow Storybook with Mariana C. Fernandez
Name (first and last) *
Email *
Phone *
School Name (please write the official name). *
Ward *
Please select the grade levels of students that will be attending: *	Pre-K K 1 2 3 4 5 6 7 8 9 10 11 12
Number of students attending: *
Number of adult chaperones attending: *
How many separate classes make up the total number of students above? *
Please provide the name and email of your school's Business Manager (MSL/DSL). *
Please provide the name and email of your school's Principal. *
If you are filling out this form on behalf of another teacher, please list their contact information here (Name, email, and phone number): *
Is your school considered Title I? *	Yes No
Please share any accessibility measures needed for your students (we will do our best to accommodate these, but they are not guaranteed): *
If available, will you need printed materials in:	Spanish Amharic
Have you ever signed up for an arts and humanities field trip before now? *	Yes No
Did you turn in the appropriate field trip application upon requesting this program? *
I will ensure that my students and I will complete the assessment surveys provided by the DC Collaborative within 1 week of completing the learning experience. *
I have read, understand and will abide by the School Partner Community Standard form. *	Yes No
I understand that "Glow-box Shadow Storybook" takes place on a Monday, Wednesday, or Friday and that the exact date and time for this program will be scheduled directly with the Provider. *	Yes
I understand that because this is a virtual program, a teacher must be present in the classroom with students at all times. *	Yes
Yes, I would like to receive text messages from DC Arts and Humanities Education Collaborative. Don't miss upcoming events! Text message reminders will only be sent for the events you have registered for.
What's the best number for us to text you? *

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Request for Glow-box Shadow Storybook with Mariana C. Fernandez