Lower Hudson Teacher Center Network Poverty Simulation                                     Reservation Form - Kit 2 (Newburgh)
This form serves as a request.  You will receive an email confirmation  reserving a date to use the Poverty Simulation Kit (PSK).  

Poverty Simulation Kits may only be reserved and loaned out by a LHTCN director and facilitated by those who have receive training to use the PSK.


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Email *
Registration Information
Completing this form does not guarantee the PSK will be available to you.  This form as a request only.  Based on availability and the date of your event, you will receive your confirmation of loan.  You are requesting the PSK that is housed at the Newburgh Teacher Center.
First Name *
Last Name *
Email Address *
Cell Phone *
Most communication will be via email.
Teacher Center *
Poverty Simulation Experience
Date of Simulation *
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Location of Simulation *
Lead Facilitator Name (must have been trained) *
Additional Facilitators(must have been trained)
Number of Participants:  (Estimated) *
Should be 55-100 participants.  
I understand that I am responsible for the pick-up and drop off of the Poverty Simulation Kit (PSK) within  2-weeks or less depending on when the next loan is.  I understand that I am expected to return the PSK in working condition.  A $10 fee will be charged for each missing or broken item*.  (*exception is non-laminated paper items)  There is a $250 Inventory Restocking Fee paid by the Teacher Center reserving the kit. *
Required
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This form was created inside of Newburgh Teachers' Association.