Visit Request Form

First name*

Last name*

Position (Teacher, Guidance Counselor, Principal, etc.) *

Email*

Phone number (also to be used day-of visit)*

School Name*

For home schoolers, please list "home school"

School Website*

School Address*

City*

County*

Would you like a virtual or in-person visit?*

Virtual

In-Person

Would you like a 60 or 90 minute visit?*

60 minute visit

90 minute visit

1st choice: Requested date of visit

Month/Day/Year

2nd Choice: Requested date of visit*

Month/Day/Year

3rd Choice: Requested date of visit*

Month/Day/Year

Requested Time of Visit*

Please note visits are usually 90 or 60 minutes, so please include a note below if you prefer a different length of time. Also please indicate in comments below if and which any other windows of time might work.

Number of 7th grade students*

Total number of 7th graders in all classes

Number of 7th grade classes*

How many classrooms will be participating in the session? Classes can be combined for the presentation, or we can visit individual classrooms, depending on Ambassador availability.

Description of class

Any information that could help us best prepare... Any special needs? etc...

Are there other languages spoken by students in class? Spanish speaking only? If so, which languages and approx. how many students?*

We can't guarantee we will have multilingual Ambassadors available at the time of your visit, but we will do our best.

Our presentation includes a fun power point with videos and great images of campus. If requesting an in-person visit, can we log into our UW account from your laptop to present our power point?*

If not, we will plan to present with out a power point.

yes

n/a

Anything else we need to know?

Parking, length of visit, notes on time of visit, accessibility, etc.

Is media welcome for your event?*

yes

Instagram Username

Bucky's Classroom is on Instagram! https://www.instagram.com/buckysclassroom/ Let us know your school's Instagram username, and we will tag you!

Can the University of Wisconsin-Madison use images and/or testimonials from your visit for promotional purposes?*

Yes