Videoconference Registration Request Form

Please carefully fill in and submit the form below. You will be notified via e-mail of the acceptance of your request. Please use one request form for each lesson requested.

The Smithsonian National Air and Space Museum respects your privacy. Please see our privacy policy for more information.

* Fields marked with a red asterisk are required.

PROGRAM INFORMATION

*Program Title:
*Preferred Program Date :	MM/DD/YYYY (One month advance notice required.)
*Preferred Program Time:
*Grade Level or Type of Audience:
*Number of Participants:
*Your Time Zone:

CONTACT INFORMATION
Please provide your primary contact information and school address.
*First Name:
*Last Name:
	A valid email address is required.
*E-Mail:
*Confirm E-mail:
*School Name:
*School Address 1:
School Address 2:
*City:		*State:
*Zip Code:		Country:
*Phone:	XXX-XXX-XXXX

TECHNICAL CONTACT INFORMATION
Please provide contact information for the person responsible for technical aspects of videoconferencing (if other than yourself).
First Name:
Last Name:
E-Mail:
Phone:	XXX-XXX-XXXX
*IP Address:	(for videoconferencing unit)

Comments or Questions?:

Participation requirement: By submitting this request you agree to participate in a pre-lesson videoconference which will be scheduled no less than one week prior to the date of the videoconference lesson with the students. This will provide a "getting-to-know-you" opportunity for lesson presenters and the teacher(s) who will participate in the videoconference lesson.

* Please check this box to agree to the pre-lesson participation requirement.