Illinois Holocaust Museum & Education Center

Outreach Request Form

Please note that if you have already scheduled a field trip with the Museum, you should not submit a speaker request form. Whenever possible, a speaker will be included as part of your scheduled field trip.

IHMEC requires a minimum of 60 students to schedule an outreach visit. Groups must be located a minimum of 60 miles from the Museum. Groups located less than 60 miles from the Museum should schedule a school field trip or non-school group tour.

	Classroom Speaker Outreach Visit (Grades 6 and Up)
School/Organization Name*:
Contact Person*:
Work Phone:
Home or Cell Phone:
School Address:
School City:
School State:
School Zip:
Fax:
Email*:
Grade Level of School:
Subject Taught:
Grade Level of Class (6+):
Number of Children:	Number of Adults:
School Type:	Other:
If you would like to request a specific speaker, please write his/her name here:

Date and Time of Visit
First Choice*: , Time:
Second Choice: , Time:
Third Choice: , Time:
Students' Degree of Preparation
How many days and/or weeks have your students studied the Holocaust prior to their visit?

What have your students read or are currently reading about the Holocaust?

What films or movies have your students viewed about the Holocaust?