First Name:

Last Name:

Grade:

School:

Mailing Address:

City:

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Zip Code:

School Phone:

Alternative Phone:

Email Address (needed for your confirmation):

I wish to borrow the following video(s): (maximum of two)

When would you like to receive your video(s):

First Choice (MM/DD/YY) :

Second Choice (MM/DD/YY) :

How many people will watch the video(s):

Please print this form for your records before submitting.