Registration Form for Poetry Out-Missouri

Fax to: Virginia Sanders (314-340-7215)

Mail to: Virginia Sanders-Poetry Out Loud

Missouri Arts Council

815 Olive St. Suite 16

St. Louis, MO 63101-1503

Email to: virginia.sanders@ded.mo.gov

DEADLINE: November 30, 2009 Postmarked

________ Yes, our high school would like to participate in Poetry Out Loud.

School District

Name of High School _________________________________________________

High School Address _________________________________________________

City/Town/Zip code ________________________________________________

County _________________________________________________

High School Phone Number _____________________________________________

School Coordinator ________________________________________________

Alternate Coordinator Phone Number

Email Address

High School Fax Number _______________________________________________

Principal’s Name______________________________

You may attach additional pages if needed. List the name of teacher, class, grade level, number of students, for each class participating:

NAME OF TEACHER

CLASS

GRADE LEVEL

# Of STUDENTS PARTICIPATING IN POL Program