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Discovering the Science of the Environment


 

 Program Request Form

First Name:    
Last Name:    
School Name:    
 School Address
Street Number and Name:		    
School City:    
School State:    
School Zip:    
School Telephone Number:   Extension:  
 Email Address:    
Preferred Method of Contact:    
Grade Level Receiving Program:    
Approximate number of students receiving program:    

Please provide three possible dates and times for programming in order of preference:

        
Time (Ex: 1:30 to 3:00)

Time (Ex: 1:30 to 3:00)

Time (Ex: 1:30 to 3:00)
 		  

Do you have an existing outdoor laboratory or nearby natural area?

    
If yes, what type of environment? Be as specific as possible.    
Program Request:    
Additional Requests or Comments:    

 

Center for Earth and Environmental Science
 School of Science
 Indiana University~Purdue University, Indianapolis
 723 West Michigan Street, SL118
 Indianapolis, IN 46202
 www.cees.iupui.edu
 cees@iupui.edu