Community Outreach Program Request Form

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Organization or Group name:

Group Leader/Contact:

Email: Phone:

Street Address:

City: Zip: County:

Program Request
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Program Location (if different from above):

Estimated Number of Program Participants: Youth Adults

Library Summer Reading Program Information (if applicable):
Summer Reading Program Dates (start - end):  
Day(s) of the Week:   Time(s):

List available dates/times in order of preference for scheduling:

1st Choice Date:   Time:  
2nd Choice Date: Time:
3rd Choice Date: Time:
4th Choice Date: Time:
5th Choice Date: Time:
 How flexible is your location regarding scheduling a program outside of these dates and times?

 Additional Comments

Cost: Program fee for a Library Family Program is $110 plus travel expenses (mileage at $0.545/mile outside the Eugene/Springfield area and additional fee for overnight stay if necessary for program delivery). Fees for other community outreach programs will be determined based on specific program requests.