What type of organization are you?*Please explain
School/Organization Name*
School/Organization Street Address 1*
School/Organization Street Address 2
City*
State or Province*- Please Select - District of ColumbiaMarylandVirginiaAlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontWashingtonWisconsinWest VirginiaWyoming
Zip or Postal Code*
School Telephone*
Fax
Organization Type*- Select -PublicPrivateCharter
Age of Audience*
Estimated number of participants attending Reading Time Out*Must be less than 50
Number of students attending Reading Time Out*
Do you have a space to host the Reading Time Out?*-Select-YesNo
*If yes, please describe space (Gym, Classroom, Courtyard, All Purpose Room, etc.)
Can you provide transportation to a location off site?-Select-YesNo
Please explain your needs
First Name*
Last Name*
Email Address*
Daytime Phone*