Science Ambassadors

Science Night Request

Cost: $250 (1 Hour Show)

**Please note: This request form is not a show confirmation. You will be contacted soon to confirm availability.

SCHOOL
School Name *
School District *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
CONTACT
Contact Name Contact Name * First Last
Email *
Daytime Phone Daytime Phone * - ### - ### ####
Evening Phone Evening Phone * - ### - ### ####

Phone number for the night of the event.
SCHEDULING
1st Choice Date 1st Choice Date * / MM / DD YYYY
Time *
2nd Choice Date 2nd Choice Date * / MM / DD YYYY
Time *
Anticipated Attendance *
ADDITIONAL INFORMATION
Is the venue carpeted? *

Is the venue carpeted? Yes No
Comments

Science Ambassadors

Science Ambassadors

SCHOOL

CONTACT

SCHEDULING

ADDITIONAL INFORMATION