Outreach Request Form

Our outreach programs are designed for up to 30 students and last 45 minutes with a 15 minute transition time. We normally will not exceed four groups per day, so a second date may be necessary to serve more than 120 total students. There is a $1.00 per student fee, plus a $15.00 trip charge. Please note that a second date will result in an additional $15 trip fee. For each date choice, enter the time slots needed for each group of students.

*Indicates a REQUIRED field

Please complete the following:
*Coordinator's Name:

*Coordinator's E-mail:

*Coordinator's Phone Number:

*School/Group Name:

School/Group Phone Number/Extension:

District/City:

Address of Program Location:

Cross Streets:

OUTREACH TOPIC: Please select your outreach program topic:

Arizona's Water
Bizarre and Beautiful Bugs
Digging for Dinosaurs
Discovering the Lives of Ancient People
Seed to Flower to Seed
The Science of Snakes

FIRST DATE
*Enter your first date choice:     MUST be in this format: mm/dd/yyyy

Time slot 1:
Time slot 2:
Time slot 3:
Time slot 4:

SECOND DATE
*Enter your second date choice:     MUST be in this format: mm/dd/yyyy

Time slot 1:
Time slot 2:
Time slot 3:
Time slot 4:

If alternate dates are available, please note them in the comments section below.

*Total # of students:     (Enter a number only!)

Grade level:

Payment Method: Purchase Order   Cash or Check