Holocaust Survivor 2015 Registration Form
The Institute for Holocaust Education, Educational Service Units 2 and 17, and Wahoo Public Schools are pleased to offer two March 25, 2015 presentations by Holocaust survivors:  a morning presentation from 10 AM  to 11:30 AM featuring survivor Fran Malkin  and an afternoon presentation from 1:30 PM to 3 PM featuring survivor Agnes Schwartz, with final 30 minutes of each session for Q&A from audiences. It is possible to both transport students to Wahoo and to connect others in your school or community via Video Conferencing Technology.
Complete all responses for each presentation session in which you plan to participate. Your complete information is critical to the success of the event.  Thank you!
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Please enter School or Distict Name *
Use official name, as will be featured in event news stories.
Indicate which Educational Service Unit region Number your school is associated with. *
ENTER NUMBER ONLY!
We will participate in the 10:00 AM presentation on March 25, 2015
If your interest is in the afternoon session, keep scrolling down. Keep in mind that it is possible to both transport and connect.
How many 10 AM auditorium seats will you reserve.
The auditorium will seat 733. Registrations are date and time stamped at the time of your submission, and seating reservations will be honored accordingly.
How many 10 AM Distance Learning participants will be involved.
The Institute for Holocaust Education reports these numbers to its donors; please be specific.
Provide the 10 AM session IP Address of your codec.
If you do not have a room or cart VCT equipment it is possible to join via desktop conferencing and project to a large screen.
Describe your 10 AM student audience(s).
Include student grade level(s), course title descriptors, and teacher names.
We will participate in the 1:30 PM presentation on March 25, 2015.
Keep in mind that it is possible to both transport and connect.
How many 1:30 PM auditorium seats will you reserve.
The auditorium will seat 733. Registrations are date and time stamped at the time of your submission, and seating reservations will be honored accordingly.
 How many 1:30 PM Distance Learning participants will be involved.
The Institute for Holocaust Education reports these numbers to its donors; please be specific.
Provide 1:30 PM session IP Address of your codec.
If you do not have a room or cart VCT equipment it is possible to join via desktop conferencing and project to a large screen.
Describe your 1:30 PM student audience(s).
Include student grade level(s), course title descriptors, and teacher names.
Last Name, First Name of individual coordinating school participation. *
Provide only 1 coordinator for your entire school. Registration confirmations and event communications will be directed to this individual.
E-mail Address of individual coordinating school participation *
Phone Number of individual coordinating school participation *
Be sure to include area code and extension.
Last Name, First Name    of Distance Learning Technology Specialist
This individual must be available for a system check scheduled prior to presentation date AND be available to troubleshoot during all sessions for which you register.
E-mail Address of Distance Learning Technology Specialist
Phone Number of Distance Learning Technology Specialist
Be sure to include area code and extension.
Mobile Phone Number for troubleshooting site connections during presentations
Be sure to include area code. SEND TEXT MESSAGES.
I would like a DVD of Survivor presentation (if Survivor gives recording consent and video capture is sufficient quality).
By choosing an option below, I agree to pay ESU 2 $10 for production/shipping.
Shipping Address if requested DVD
Shipping will be via United States Post Office (USPS) media rate.
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