HAVE A GREAT IDEA FOR A PROGRAM?
TELL US ABOUT IT!

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Intended Audience *

All Ages

Seniors (60+)

Adults

Teens (13+)

Children

Topic or Area(s) of Interest: *

Fine Art

Arts/Crafts

Book Talk

Music Performance

Hobbies/Life Skills

Science/STEM

Other

Preferred Date & Time

MM

DD

YYYY

Agree to theLPL Policies *

I have read the Program Room Use Policy (above this form) and agree to comply with them. I will assume responsibility for any damages and will leave the room in a neat and orderly condition.

I Agree