Interactive Classroom Assignment Request
Student Name
(Required)
First
Last
Course # & Name:
(Required)
Phone
(Required)
Email
(Required)
Professor Name
(Required)
First
Last
Department
(Required)
Phone
(Required)
Email
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Title of Assignment
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Describe the assignment and how you will interact with ECDC children or parents.
(Required)
(Please attach copy of the written assignment from the instructor).
(Required)
Max. file size: 1 MB.
Desired participants: (number of individuals in each category)
Number of Children
Two years old
(Required)
Three years old
(Required)
Four years old
(Required)
Five years old
(Required)
Number of Teacher(s)
(Required)
Number of Parent(s)
(Required)
Other (please explain):
Center Facilities or accommodations needed:
(Required)
What days/times do you request to complete your assignment:
(Required)