Note: Speakers in the Schools lectures are primarily for high school students; however, they may be presented to a combination of students and others such as teachers or parents.

Host School Information
* Type of School	Public Private (includes parochial and other religious schools)
* Name of School
* Address
* City
* State
* ZIP Code
* Phone Number
Lecture Coordinator
* Name
* Position at School
* Address
* City
* State
* ZIP Code
* Phone Number
Fax Number
* Email Address
Program Requested
* Name of Speaker
* Lecture Title & Number
* Lecture Date & Time
* Format of the Lecture (single class session, assembly, after-school or weekend program, venue, etc.)
* Briefly describe the students (grade, class subject, etc.) you intend to reach with the lecture. How many do you expect to participate?
* How will this lecture enhance what your students are learning?
* What curriculum standards, if any, will the lecture address? If no curriculum standards will be used, please enter "n/a".
* How did you hear about the Speakers in the Schools program?
If applicable, please list previous Speakers in the Schools presentations you have hosted in the past year. Please include Speaker names and dates.
* I understand and accept the condition that Council-sponsored Speakers in the Schools presentations must be offered to a school-based audience, as well as the requirement that Council support must be formally acknowledged at the lecture and in any materials prepared about the lecture.
* I have notified and been granted permission by my school's administration to coordinate and present this Speakers in the Schools program.