Mount Ephraim Public Schools
1. This form must be submitted to the Appropriate people10 days prior to a planned Distance Learning activity. Make five copies. Send copies to the Business Office, Carol Sweeny, the main office (Linda Guldin at Kershaw or Carol Clark at Mary Bray), Media Center (Kitty at Mary Bray or Jackie at Kershaw), and keep one for yourself.
2. Teacher is responsible for making arrangements with the Presenting Organization.
3. Teacher is responsible attending to details reserving room, setup, and appearance. (To help you plan, refer to the Distance Learning Checklist and a Distance Learning Worksheets attached to this form. These forms are also available on the district’s website.)
School_____________ Teacher_______________ Grade_____________
Date of Distance Learning Activity________ Date of Application_________
Presenting Organization_______________ Telephone #_______________
Far End IP Number:__________________ Connection Rate____________
Far End ISDN Number(s)______________ Connection Rate____________
Time of Distance Learning Activity_________ Length of Activity__________
No. Of Participants: Pupils_______ Adults:________ Total:_____________
Fees: (Per Event)____________ Time/Date of Test Call:_______________
Please indicate below if you need technical support for your Distance Learning Activity. Specify if you need technical person for the duration of call or only to connect you to the site. If you require technical assistance, find out when technical person is available prior to scheduling the distance learning activity.
Please indicate any pre-planning in which the class will be involved.
Please indicate what follow-up activities are planned.