ALTA Spectrometer Classroom Set Request

Request for the Loan of a Specific Exhibit

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Contact Information

First Name:

Last Name:

Organization:

Address(1):

Address(2):

City:

* State: * Zip:

Telephone:

E-mail:

Preferred Arrival Date for Classroom Set:

Preferred Return Date for Classroom Set
(maximum of 30 days):

Other Information

Type of Organization:

School
Science Center
University
Other. Please describe:

Please estimate your audience diversity:

% Hispanic	% African American	% Caucasian	% American Indian	% Asian	% Other

How would you classify your community?

Rural Urban Suburban

How would you classify the community income level?

upper upper-middle middle lower-middle lower

Which activities or lessons will you use with the ALTA spectrometers?

Which class(es) will use the ALTAs? (Subject and grade level)

How did you learn about these traveling exhibits?

workshop
website
email from colleague
other (please describe)

Questions/Additional Information?

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If you see an error message, please correct and resubmit.