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2022-2023 Southern Research STEM School Visit Request Form
Please submit a STEM school visit request for the 2023 spring semester.
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Email
*
Your answer
Cell Phone Number
*
Your answer
School Name
*
Your answer
School District
*
Your answer
County
*
Choose
Autauga
Baldwin
Barbour
Bibb
Blount
Bullock
Butler
Calhoun
Chambers
Cherokee
Chilton
Choctaw
Clarke
Clay
Cleburne
Coffee
Colbert
Conecuh
Coosa
Covington
Crenshaw
Cullman
Dale
Dallas
DeKalb
Elmore
Escambia
Etowah
Fayette
Franklin
Geneva
Greene
Hale
Henry
Houston
Jackson
Jefferson
Lamar
Lauderdale
Lawrence
Lee
Limestone
Lowndes
Macon
Madison
Marengo
Marion
Marshall
Mobile
Monroe
Montgomery
Morgan
Perry
Pickens
Pike
Randolph
Russell
St. Clair
Shelby
Sumter
Talladega
Tallapoosa
Tuscaloosa
Walker
Washington
Wilcox
Winston
Out of State
Class/Subject
*
Your answer
Grade Level
*
Please select all that apply.
K
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Required
How many total students will be attending?
*
Your answer
Outreach Option
*
Choose
In-Class Demo - Acids, Bases, and Ocean Acidification
In-Class Demo - The Magic of Static Electricity
In-Class Demo - DNA Extraction
In-Class Demo - Wacky Waving Wands
Large Scale Demo - Science Demo Show
In-Class Presentation - Career Day
Date Option 1
*
MM
/
DD
/
YYYY
Date Option 2
*
MM
/
DD
/
YYYY
Date Option 3
*
MM
/
DD
/
YYYY
Details of Visit
*
Please provide any necessary details about the school visit (e.g., COVID protocols, space available for demonstration, number of sessions, etc.).
Your answer
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