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Mad Science After School Program Request Form
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* Indicates required question
Email
*
Your email
School or Organization
*
Your answer
Contact name
*
Your answer
Phone Number
*
Your answer
Position
Your answer
Topic
*
Choose
Crazy Chemworks (Grades K-5)
Minerals, Machines, Movies (Grades PreK-4 Preferred)
Brixology (Grades 1-5)
Unsure
Preferred Start Date
*
MM
/
DD
/
YYYY
Preferred Day
Choose
Monday
Tuesday
Wednesday
Thursday
Friday
Start Time
Time
:
AM
PM
Number of Sessions
*
Choose
4
5
6
7
8
8+
Classroom (if known)
Your answer
Dismissal Policies (Optional)
Your answer
Additional Requests or Comments
Your answer
Please send me special offers and cool experiments
Yes
No
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