Scheduling Services for Your School

Your Name *

Alternate Contact Person *

School Name *

School Address

School City

State

Zip

Position *

Email Address *

Phone Number *

Fax Number *

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Name of Program Requested *

Date for Program Implementation *

Alternative Date for Program Implementation *

Time for Program Implementation *

Audience *

Number of Participants *

Grade Level *

Room Number *

Fields marked with * are required.

If you would like to schedule programs by fax and/or email, please complete and return the program request form below.

Download our scheduling form Program_Request_Scheduling_Form_2010-2011.pdf (97 KB)

Please contact us with program requests as soon as possible as some programs are popular and fill up quickly. Send your completed scheduling form to Sara Turk by fax (312) 243-3954 or email at sturk@lungchicago.org.

If you would like to schedule programs for your school, please contact:

Sara Turk
Project Coordinator
(312) 628-0259
sturk@lungchicago.org

Service Matching

Scheduling Services for Your School