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High School Pre-Release Screening Request Form
Full Name
*
Prefix
First Name
Last Name
Title
*
E-mail
*
Phone Number
*
-
Area Code
Phone Number
High School
*
High School Address
*
Street Address
Street Address Line 2
City
Please Select
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District of Columbia
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New Hampshire
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New York
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Approximate Student Body
*
Screening Date/Time Request (1st Choice)
*
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Day
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Month
Year
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:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Screening Date/Time Request (2nd Choice)
*
-
Day
-
Month
Year
Date Picker Icon
1
2
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12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Screening Date/Time Request (3rd Choice)
-
Day
-
Month
Year
Date Picker Icon
1
2
3
4
5
6
7
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9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Is your school willing to host screening for entire student body?
*
YES
NO
If NO to the question above, please explain why.
*
Technical reasons (no equipment to show film to school, etc)
Date for student body showing unavailable
Not willing to host school assembly
Other
If you are not able to host the screening for the entire student body, please describe how you suggest showing the film in as few showings as possible to the student body.
*
If YES, please describe the logistics of screening (location of screening, how the film will be displayed, etc).
*
How much time are you allowing for the screening (50 minutes - 1 hour recommended)
*
Are you willing to have a Q&A period? It can be organized so only a limited number of questions can be answered / a limited number of students can answer questions.
*
YES
NOT
Other
Is your school able to cover the requested costs (travel/lodging of one film representative and additional $100 to cover materials)?
YES
NO
Other
Additional Comments:
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