Form

Media Violence Education Project Workshop Request Form
Name: *
School/Company/Organization:
E-mail: *
Phone: *
Date requested (not required):
# of participants *
Workshop age range *	Elementary (3rd-6th) Middle (6th-8th) High (9th-12th) Adult
Workshop choices	Eyes Wide Shut Focus on Films (adult version of Reel Talk) Game Freaks Girl Scout specific-Media Savvy Girl Scout specific-The Choice is Yours Givin' Rhythm the Blues Media Violence Sampler Mirror, Mirror in the Media MySpace or Yours Read it and Weep Reel Talk (youth version of Focus on Films) Unsure - need more info
Workshop Requirements: All MVEP workshops are performed on-site of the requesting agency or at a pre-arranged location provided by the requesting agency. Please check the requirements you are able to meet below.
....	Access to meeting area 30 minutes prior to start time and 30 minutes after end time. Adequate and comfortable seating for all attendees. Screen or smooth surface wall for projection purposes. Accessible electronic outlets. Tabletop surfaces for equipment. *optional -wireless Internet access
Additional Comments: