Let's Play Request Form

Your Name*

First NameLast Name

Email*

example@example.com

School Name*

School Town/City*

Is your program grant-funded (e.g. 21CLC)*

YesNo

What are the goals for this program? Choose 1 or 2.

Creative & Artistic Development (introduce students to new skills, encourage self-expression, etc.)Social & Emotional Growth (encourage teamwork, communication and problem solving)Academic & Cognitive Development (enhance literacy skills, language development, critical thinking, etc.)Engagement & Enrichment (organize a fun, hands-on experience)

Are there any behavioral or social-emotional challenges among students that the teaching artists should be aware of?

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Emergency contacts will be notified of any last-minute updates, such as delays or logistical changes.

On-Site Contact Name*

First NameLast Name

On-Site Contact Phone*

Please enter a valid phone number.Format: (000) 000-0000.

The on-site contact is the person responsible for supervising the program in the space or nearby.

The On-Site Contact will be:*

Present in the program space with the teaching artistFloating between spaces and checking inNearby and available if neededNot sure

Format Choice*

1 hour (1 session) per day: $257 per day2 hours (2 sessions) per day with single teaching artist: $310 per day2 one hour sessions per day (two teaching artists): $514 per dayNot sure

Grade Level(s)

Number of Students per Session

Up to 30

How will the grades be divided?

For example, K-2 and 3-5

Student Attendance Expectations

Drop In: each session might have a different mix of studentsRegular Attendance Encouraged: most students will attend every session but there might be some inconsistenciesConsistent Attendance Expected: students will sign up to participate and be expected to be there

Days of the Week

Monday

Tuesday

Wednesday

Thursday

Friday

Total Days

Number of Weeks

4 week minimum commitment

Start Date

Workshop Time(s)

Program Cost (read only)

Does not include any possible material fees.

If some visual arts sessions are scheduled, I am able to cover material fees or provide what is needed:*

YesNoI'm not sure

Questions/Additional Information

By signing here, I acknowledge that an authorized adult will be present in or near the program space and reachable at all times. I also understand that the teaching artists are not responsible for collecting or escorting students to or from locations outside the program space.

Signature

By initialing here, I acknowledge that an authorized adult will be present in or near the program space and reachable at all times. I also understand that the teaching artists are not responsible for collecting or escorting students to or from locations outside the program space.*

Your Contact Information

School Information

Program Contacts

Let's Play Program Information