Reading and Discussion Program Request Form

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Reading and Discussion Program Request Form

Before submitting this form, call VHC to tentatively reserve the series. Forms should be submitted no later than 6 weeks before your first scheduled session. At this time we are unable to accept payment online, full payment details are provided on the booking confirmation.

1. Series Information

Series Requested *

Expected Number of Participants *

Date *

Day *

Time *

Book Title *

Scholar *

Scholar needs book? *
YesNo

YesNo

2. Program Site/Sponsor Information

Program Site (must be accessible to persons with disabilities) *

Address (we cannot ship books to a PO Box, include street address) *

City *

State *

Zip *

Sponsoring Organization (if different than site)

Sponsoring Org Website

Collaborating Organization (if applicable)

Collaborating Org Website

3. Book Shipping Address
If your site address is a PO Box or you would like to receive books at a different address, please enter a shipping address

Address

City

State

Zip

4. Program Coordinator

First Name *

Last Name *

Affiliation

Phone *

Address (if different than site address)

City

State

Zip

5. Publicity Contact
If different from Program Coordinator

First Name

Last Name

Affiliation

Phone

6. Cost
Cash match, books, and completed evaluation forms must be remitted to the council within 2 weeks after the end of the program. Sponsoring organizations may not charge fees to participants

Also send me a copy

* Required