Name of person completing this form*

Position*

Email*

Phone*

Name of School*

Address*

City*

State*

Zip*

Estimated number of students who will see the film*

Who will facilitate the screening and discussion?*

Date of screening*

What year in high school are the students?*

Will the screening be held when school is in session or outside of school hours?*

In addition to students, will anyone else see the film?*

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