Phone: Fax: Enrollment:

Address:

City: State: Zip:

Principal: PE Teacher:

Contact Person: Phone:

e-mail address:

2. Is the facility for the show a multi-purpose room/cafeteria? Yes No (if no, skip to question 5)

3. If so, is breakfast served? Yes No For how many students?

4. What time does lunch begin? End?

5. Is the facility for the show a separate gymnasium? Yes No

6. Are there windows and/or skylights in the room? Yes No

7. If so, can they be covered? Yes No

8. Will the school be able to show a seven minute video to
every student 24-48 hours prior to Doug and HIP-D's visit? Yes No

9. Are you familiar with our new donation requirements? Yes No

Completed By: Today's Date: