HMLA Virtual Survivor Speaker Request

Name of Organization or School
Do any of the following aplpying to your students?

Do any of the following aplpying to your students? Title I Schoolwide Program At least 50% of my students receive free or reduced lunch None of the Above
Teacher/Contact
Lead Teacher/Contact for Day of Virtual Tour Lead Teacher/Contact for Day of Virtual Tour First Last
School/Organization Address School/Organization Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
School District
Type of Event:

Type of Event: Classroom Speaker Assembly Speaker Other Other
Teacher/Contact Email
Cell (for day-of contact)
Number of attendees
Age Level

Age Level 4th Grade 5th Grade 6th Grade 7th-8th Grade High School College If Other If Other
Age range of atteendees
Has your school/organization ever visited Holocaust Museum LA in the past? If so, when?
Date Requested Date Requested / MM / DD YYYY
Alternative Date Alternative Date / MM / DD YYYY
Start Time Requested Start Time Requested : HH MM AM/PM
Alternative Start Time Alternative Start Time : HH MM AM/PM
How long does the survivor/speaker have to speak?

Speakers require a minimum of 45 minutes to speak.
Tell us about your class/organization
Please tell us about your group, their familiarity with the Holocaust and any books, literature, or films they have learned from:
How did your hear about Holocaust Museum LA?