School Name*

Teacher Contact Name*

Contact Email Address*

Contact Phone Number*

School Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

First Preferred Month for Program*

Second Preferred Month for Program*

Third Preferred Month for Program

Preferred Grade for Program

School Start Time*

Lunch Period for Preferred Grade*

Total Number of Students to Participate in the Program*

Total Number of Classes to Participate in the Program*

Is your school a Title I school?*

Please briefly explain how Art Outreach would enhance or benefit your student’s learning experience. In other words, why do you want your school to participate in this program?

Art Outreach Program

Art Outreach Form