Scientist in the Classroom Program
This is a sample teacher's request form.

Teacher's Request Form

Please send one form for each request at least 5 weeks in advance of the desired date for the visit.

Teacher's Name:_________________________________________

School/Track:___________________________

Other Teachers?(name)__________________________________

School System:_________________________

Grade Level:________________________________________________

School Phone:__________________________

(and special considerations)

#Classes and/or Students:_______________________________

Home Phone:____________________________

I would like a volunteer to come on:____________________________________________
(day and date) (time period)

Can you be flexible regarding date and time to accomodate the volunteer's schedule?
Yes/ No

(elaborate if necessary)________________________________________________

Activity Requested:__________________________________________________________

(Include Activity Number if topic is selected from the Activity Manual)

Will the visit be part of your current curriculum: (circle one) Yes/No

If Yes, will the visit serve as an introduction to the topic: Yes/No

Comments:_________________________________________________________________

Please make sure you contact the volunteer before the visit.

Signature:___________________________________________