EarthTeam
Environmental Expert Speakers Bureau Request Form

Teacher Name: _______________________________________________________________

Teacher E-mail: _______________________________________________________________

Teacher Phone: ______________________________________________________________

School Name: ________________________________________________________________

School Address: ______________________________________________________________

School County: _______________________________________________________________

Topic for Which You Would Like a Speaker: _________________________________________

Number of Students Expected: ___________________________________________________

Grade/Club: __________________________________________________________________

Please indicate your preferred dates for the speaking engagement (please be aware that we cannot guarantee this date but we will try):
1st Choice______________________ 2nd Choice______________________ 3rd Choice______________________

Please indicate 1st, 2nd, 3rd choice day of week for speaker visit:
__Monday __Tuesday __Wednesday __Thursday __Friday __Saturday __Sunday

Please indicate 1st, 2nd, 3rd choice time of day for visit:
___ 8am-11am ____11am-2pm ____2pm-5pm

Return to:
E-mail: Laura Grossmann at LauraG@earthteam.net

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