Teacher name:
*
First Name
Last Name
School name:
*
School address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred email:
*
example@example.com
Preferred phone number:
*
-
Area Code
Phone Number
Grade level:
*
Class type:
Beginning journalism
Advanced journalism
All-level journalism
Yearbook only
English class
Other
How many years have you been teaching this type of class?
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Less than one year
1-4
5-10
10+
Publication type(s)/student media produced (check all that apply):
Newspaper
News website
News magazine
Yearbook
Broadcast TV
Radio
Other
Does your staff produce multimedia packages?
*
Yes
No
What level of training (if any) do you have in journalism and/or journalism education? (Check all that apply.)
Professional journalism experience
Certified Journalism Educator/Master Journalism Educator
Degree in journalism or related field
None
Which topic/skill would you like a professional to address with your class? (Select up to three topics.)
Data journalism
Editing
Legal briefs/libel policy
Media literacy/fake news
Reporting basics
Which best reflects the primary reason for your request? (Choose all that apply.)
To address an important topic/skill I have not taught
To supplement my own instruction on this topic
Other
Have you used guest speakers in this class before?
*
Yes
No
Which type of presentation best meets your needs? (Choose your preference.)
*
In-person visit
Skype or Google Hangout visit
No preference
What other background would you like to provide about the class and/or student media program?
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