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Experience Dyslexia Simulation Request Form
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Name of Group/Organization Making Request:
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Address of Group/Organization: 
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Name of Contact Person:
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Contact Person Email:
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Contact Person Phone:
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Requested Date of Event: 
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Attendee Type: (check all that apply)
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Number of Attendees:
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Event start time:
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Event end time:
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Location of event (street address and room #):
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Would your group like to apply for a need-based scholarship to help cover some of the costs of the simulation materials? 
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Name and contact information for person at your organization responsible for payment:
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Other comments/questions:


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