On The Road Program Request Form

Thank you for your interest in the Rock and Roll Hall of Fame and Museum Distance Learning Programs. Please submit one form for each program and/or teacher request via fax or email. Registrations must be received at least 3 weeks prior to the requested date and are booked on a first come, first served basis. Organizations must agree to abide by the terms and conditions outlined in "Policy Information" in order to have their registration request processed. If you have any questions regarding scheduling, please contact John Goehrke at 216-515-1202.

Click here to go back to the Rock Hall's distance learning home page

Fields that are in bold are required.

Select an On the Road Program

Date/Time: First Choice

Please list your top choice. All times should be Eastern Standard Time.

Date/Time: Second Choice

Please list your second choice. All times should be Eastern Standard Time.

How did you hear about On The Road?

School Name

Videoconferencing Site Name (if different)

School and/or Videoconferencing Mailing Address

Videoconferencing Room Phone Number:

Number of Students Participating

Requesting Teacher Name

Requesting Teacher Title or Grade/Subject

Requesting Teacher Office Phone

Requesting Teacher Mobile Phone

Requesting Teacher Fax Number

Requesting Teacher Email address

Site/Technology Coordinator Name

Site/Technology Coordinator Title or Grade/Subject

Site/Technology Coordinator Office Phone

Site/Technology Coordinator Mobile Phone

Site/Technology Coordinator Fax Number

Site/Technology Coordinator Email Address

Local Bridge/Gateway Contact Name (if applicable)

Local Bridge/Gateway Contact Title or Grade/Subject (if applicable)

Local Bridge/Gateway Contact Office Phone (if applicable)

Local Bridge/Gateway Contact Mobile Phone (if applicable)

Local Bridge/Gateway Contact Fax Number (if applicable)

Local Bridge/Gateway Contact Email Address (if applicable)

Videoconferencing System Manufacturer and Model

Connection Speed

IP address/ISDN number

Billing Information Name

Billing Information: Organization

Billing Phone Number

Payment Method

NOTE: To submit credit card information, please contact John Goehrke at (216) 515-1202

Submitted By: Name

Submitted By: Phone

Submitted By: Email Address

I have read and agree to the terms as noted on the "Policy Information" Page. (Link available at top of page)