School/Organization Name*

School/Organization Complete Mailing Address*

School/Organization Phone Number*

Contact Full Name*

Contact Phone Number*

Contact Email*

Please select type of school/organization*

Is your school part of the MDCPS?

If yes, does your school receive Title 1 funding?

Grade level of students/participants*

Number of students/participants attending the outreach*

Frost Science is dedicated to offering a memorable experience for all students/participants, including those with special needs. Please help us prepare for our visit by telling us about your students/participants and any modifications or accommodations they may need. Please check any of the categories below that apply to your students/participants.*

Does your group have any accessibility needs or require any special accommodations that are not listed above or require further explanation? Please tell us anything else about your group, so we can better plan our visit.

Please list below, in order of preference, the date your group would like to have this outreach.

Preferred Date #1:*

Preferred Date #2:*

Preferred Date #3:*

Please share your preferred start time*

Please select your outreach option:*

By submitting this form, you are requesting Frost Science staff to come to your location with an outreach program. If the date requested is available, an invoice will be sent to the email on this form within 5-10 business days. Please note that a 25% deposit is required to hold your outreach date. Full payment is due 10 business days before your outreach program.

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