T1 Outreach Request Form

Contact Information

Contact Name *

First

Last

Contact Email *

Contact Phone *

School / Organization *

School District *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Does your school receive Title 1 funds? *

Yes
No

*Your school may be grant recipient eligible

What percentage of your school is low income?

More than 40%
Less than 40%
Unsure

Outreach Requests Info

Outreach Type *

In Person (At your school)
Virtual

Please note that schools outside a 15 mile radius will be charged a travel fee.

Grade Level(s) *

Total # of Students *

Special Education Accommodations Needed?

Outreach Requests

Outreach Date / Time Preference 1 *

Date

Time

Outreach Date / Time Preference 2 *

Date

Time

Outreach Date / Time Preference 3 *

Date

Time

Outreach Date / Time Preference 4

Date

Time

Full descriptions and grade levels found in our Educator's Guide at (www.MindStretchingFun.org)

WOW Stage Shows: (30-45 minute shows held in classrooms or auditoriums for up to 150 students at a time)

You may select multiple WOW Stage Shows
$325 for the first performance, $200 for each additional performance

Learning Labs: (30-45 minute classroom programs held for up to 24 students at a time)

You may select multiple Learning Labs
$225 for the first Learning Lab, $175 for each additional Lab

*Requests are not guaranteed Outreach Reservations.

Outreaches are only guaranteed once a signed contract and deposit have been received.

If you have any questions, please contact our booking department at bookit@scitechdiscovery.org, or call us at 469-896-2188 X2.

Today's Date: *

Notes: