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Junior High/Senior High Science & Technology Presentation
Request Form

*Required fields are marked with an asterisk, everything else is optional.

*Teacher name:

First  Last

*School name:

*School address:

*City

*Postal Code:

*School phone #:

*School fax #:

Alternate phone # (if available):

Best times of day to reach you by phone:


times of recess, lunch, dismissal etc.

E-mail address that you check regularly:

*Ist choice: select from drop down menu at right

*2nd choice: select from drop down menu at right

*3rd choice: select from drop down menu at right

* Grades:

*# Classes:

*# Students per class:

*Approximate date for presentation:
(allow 4-6 weeks notice so that we can find the best match)
e.g. mid-December, early May
 
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 September 2004
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