Media Request Form

Select a Language On selecting an option from the following Language drop-down list, the language of the content will change accordingly.

Please correct the following errors.

Media Outlet Question is mandatory

Scope of Focus Question is mandatory

LISD only

Regional (Central Texas)

State-wide

Other (Please specify)

Reporter Name Question is mandatory

Phone Number Reporter Question is mandatory

Email of Reporter Question is mandatory

Have they already talked to a parent? Question is mandatory

Yes

No

Pending

Topic

Questions/Requests Question is mandatory

End Product Question is mandatory

Print

TV news

Digital

Radio

Magazine

Other (Please specify)

Date Deadline Question is mandatory

(MM/DD/YYYY)

Time Deadline Question is mandatory

What would you like to submit? Question is mandatory

Question

Concern

Compliment

Tell us who you are Question is mandatory

(Select one or more)

Enter the characters as shown in the image Question is mandatory

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