STEM on the Road Class Request Form

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Contact Information

Name *

First

Last

Your Title *

• Lead Teacher
• Administrator
• Parent
• Other

Email *

Choice) if access

School Information

School Phone Number *

School Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Are you a Title 1 School? *

• Yes
• No

STEM on the Road Class Information/Options

Select Class Program *Vermiculture [Grades K-3rd]Microscopes [Grades K-3rd]Bird Beaks [Grades K-3rd]Environscape/Potomac [Grades 4th-6th]Soil Testing [Grades 4th-6th]Water Testing [Grades 4th-6th] (Must have access to natural water on school property.)Middle School Special/Custom ClassHigh School Special/Custom Class

How many student desks/tables are available in the classroom to utilize for program materials/activities? *

Do you have easy access to a sink if needed? *

• Yes
• No

Desired Outreach Class Date (First Choice) *

Desired Outreach Class Date (Second Choice) *

Desired Outreach Class Date (Third Choice) *

Submit