Today's Date:_______________
Name:____________________ Grade:_________________________
Address:__________________ Subject:_______________________
School Phone:______________ Home Phone:____________________
Room Number:______________ Best Time to Call:_______________
Date Requested:_____________ Time Requested:________________
School:____________________ No. of Students:________________
Demo Requested: 1.____________________2.__________________
Teacher's Signature:_______________________________________
Principal's Signature:______________________________________
Harriet Hare
USCA Box 3
171 University Pkwy
Aiken SC 29801