NCCBPE
PO Box 1686
Oakland, CA  94604
(510) 632-9736

School Request Application

Name of School:  ________________________________________________________________

Contact Person:  __________________  Title:  ______________________ Grade level:  _______

Address:  ______________________________________________________________________

Phone:  ____________________  Fax:  ____________________  e-mail:   ___________________

I,_______________________________________ have reviewed the list of activities and assistance NCCBPE offers and make the following request(s)

______   Arranging a Field Trip at: __________________________________________________

______  Obtaining a Speaker: Topic:  __________________________  Date:   ________________

______  Request a classroom demonstration:   __________________________________________

Date____________________________________

Please contact me at:  _____________________________  Date:   _________________________

Please mail to:

Request for Assistance
NCCBPE
P.O. Box 1686
Oakland, CA  94604

or e-mail to: nccbpe_edu@hotmail.com