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Community Outreach Program Request Form
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Community Outreach Program Request Form
Organization/group name
This field is required.
Group leader/contact
This field is required.
Contact Info
Email
This field is required.
Phone
This field is required.
Address
Address
City/Town
State/Province
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP/Postal Code
County
This field is required.
Program Location (if different from above)
Estimated number of participants
Youth
Adults
Request your program
This request is for:
Summer 2024 (June - August): Journey Under the Sea
January - May of 2024
Are you located within a 90-minute drive of the museum?
Yes
No
Choose a program
- None -
Move Like A Mammoth
Engineer It! Exploring Ancient Technologies
Oregon Rocks!
Comments?
Request a program date:
The program length can be flexible from 60-90 minutes. The 90-minute length is recommended. Each program begins with a 20 to 25 minute presentation and then participants will explore a variety of activities at their own pace.
Preference 1: Date and Start Time
This field is required.
Preference 1: Date and Start Time: Date
This field is required.
Preference 1: Date and Start Time: Time
This field is required.
Preference 2: Date and Start Time
Preference 2: Date and Start Time: Date
Preference 2: Date and Start Time: Time
Preference 3: Date and Start Time
Preference 3: Date and Start Time: Date
Preference 3: Date and Start Time: Time
Preference 4: Date and Start Time
Preference 4: Date and Start Time: Date
Preference 4: Date and Start Time: Time
Preference 5: Date and Start Time
Preference 5: Date and Start Time: Date
Preference 5: Date and Start Time: Time
Is there flexibility for scheduling a program outside of these dates and times?
Yes
No
What is your preferred date range for scheduling a program (such as the starting and ending dates of your summer reading program)?
Please list any preferred days of the week and time of day for scheduling programs.
Additional Comments
