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FIRST NAME

LAST NAME

ORGANIZATION OR SCHOOL NAME

CITY & STATE OF YOUR ORGANIZATION OR SCHOOL DISTRICT?

WORK PHONE

CELL PHONE

EMAIL

COMPANY/DISTRICT WEBSITE

WHAT TYPE OF PRESENTATION WOULD YOU PREFER?

Live Performance at specified location
Virtual Performance-livestream

EVENT LOCATION?

EVENT TIME?

HOUR

--

MINUTE

--

AM/PM

--

EVENT DATE?

IS YOUR DATE FLEXIBLE?

YES
NO
MAYBE

Referred By:

ADDTIONAL MESSAGE:

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