Breakout Box Request
Please use this form to help us with planning for and filling your requests for the Breakout Boxes.
Email address *
Name of staff member that will be overseeing the activity. *
Your answer
Site *
Location of Breakout activity (i.e., library (please coordinate with your school librarian for library availability), classroom #, etc.) *
Your answer
Start date and time boxes needed *
**Please note: Our Breakout Team requires at least ONE WEEK'S notice for a request to allow for adequate time for prepping all the materials and locks, as well as delivery time.
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YYYY
Time
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End date and time boxes needed *
MM
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DD
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YYYY
Time
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For INTERMEDIATE sites:
Please indicate the class period(s), and start time and end time of that period. Please list every period that will be using the boxes. (i.e. 2nd period, 9:00-9:50 & 5th period, 12:00-12:50)
Your answer
How long will the activity run? *
(i.e. 30 minute period, 1 hour, etc.)
Hrs
:
Min
:
Sec
How many participants will there be? *
(This helps us to determine how many boxes to prepare for your class.)
Your answer
How many boxes are required? *
(4 participants per group/box is usually a good number. Please note if the Breakout game you are requesting is a DIGITAL Breakout, 0 boxes are required.)
Your answer
Would you like a teacher librarian to help run the game? *
Group that will be using the boxes (i.e. grade level, special program, etc.) *
Your answer
What is the name of the pre-made game you are requesting?
(if applicable, if not, continue to the next question)
Your answer
Is the pre-made game a DIGITAL breakout?
What is the subject/theme of a game you are interested in?
(There may be other games that the teacher librarians can access with their access codes)
Your answer
Will you be providing treats to put into the large Breakout Boxes for students who break out?
*If YES, please send the treats to the IMC noting your name and which Breakout activity they are for. Please send these treats ASAP after your boxes have been requested so that they can be included when the boxes are being set up by our team.
Additional notes we need to know about your request:
Your answer
A copy of your responses will be emailed to the address you provided.
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