Program For Schools Request

Please provide the following information to make a Programs for Schools request.
Note: Use the tab key to move to the next item. Required items are indicated with an asterisk *.

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Requested by:

School Name * :
School Phone Number * :	( ) -
Fax Number:	( ) -
Your Name * :
Home Phone Number: (if you are willing to be called at home)	( ) -
Best times to call: (Office hours are: Monday-Friday 8:30-4:30) between and Monday-Friday Monday Tuesday Wednesday Thursday Friday at home or    school between and Monday-Friday Monday Tuesday Wednesday Thursday Friday at home or    school between and Monday-Friday Monday Tuesday Wednesday Thursday Friday at home or    school between
Email Address *:

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Program Requested:

Type of program you would like to request * :	Select a type of program Self-guided Group Visit to LHS Workshop at LHS Assembly at LHS Festival at LHS Science Discovery Theatre at LHS Multi-Session Course LHS Workshop at Your School Assembly at Your School Multi-Session Course at Your School Science Discovery Theatre at Your School Festival at Your School
Grade Level * :
Number of Students Attending * :

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1st Choice

Title of Program * :
	Mon.  Tues.  Wed.  Thurs.  Fri.    Preferred Dates *: or Preferred Time of Day for: Programs Held at LHS: Select a time 10 a.m. 11:10 a.m 12:30 p.m. 1:30 p.m Programs Held at Your School: Multi-Session Programs:

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2nd Choice

Title of Program:
	Mon.  Tues.  Wed.  Thurs.  Fri.    Preferred Dates: or Preferred Time of Day for: Programs Held at LHS: Select a time 10 a.m. 11:10 a.m 12:30 p.m. 1:30 p.m Programs Held at Your School: Multi-Session Programs:

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3rd Choice

Title of Program:
	Mon.  Tues.  Wed.  Thurs.  Fri.    Preferred Dates: or Preferred Time of Day for: Programs Held at LHS: Select a time 10 a.m. 11:10 a.m 12:30 p.m. 1:30 p.m Programs Held at Your School: Multi-Session Programs:

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School Address

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School Address * :
City * :
State * :	Select a state or province AL - Alabama AK - Alaska AS - American Samoa AZ - Arizona AR - Arkansas CA - California CO - Colorado CT - Connecticut DE - Delaware DC - District of Columbia FL - Florida GA - Georgia GU - Guam HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MP - Mariana Islands MH - Marshall Islands MD - Maryland MA - Massachusetts MI - Michigan FM - Micronesia MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota OH - Ohio OK - Oklahoma OR - Oregon PW - Palau PA - Pennsylvania PR - Puerto Rico RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VI - Virgin Islands VT - Vermont VA - Virginia WA - Washington WV - West Virginia WI - Wisconsin WY - Wyoming AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NF - Newfoundland NS - Nova Scotia NT - Northwest Territories ON - Ontario PE - Prince Edward Island QC - Quebec SK - Saskatchewan YT - Yukon
Zip * :
Contact Person's Name * :
Teacher in charge of group on date of visit * :

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Comments or Feedback:

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Thank you for your inquiry. The Lawrence Hall of Science Registration Office will contact you shortly to confirm program availability, details, dates, and contract and payment requirements.