Outreach Program Request Form Outreach Program Request Form Please fill out the following form to request a Zoo to You Outreach program at your facility. THIS IS A REQUEST ONLY. Please call 520-837-8200 if you do not receive a response from the education team within 48 hours. Reservations must be made 30 days in advance of requested date. Please make sure you see a confirmation screen indicating your form has been submitted successfully. Today's Date* Date Format: MM slash DD slash YYYY Name* First Last Phone*Email* School or Organization NameOrganization Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this where the Outreach Program will take place?*YesNoAre you a Title 1 School?*NoYesLimited funding may be available to cover the cost of this program.Will the program take place indoors or outdoors?*IndoorsOutdoors (temperature dependent)Outreach Program Location* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code First date choice*Second date choiceThird date choiceDesired start time*Program topicHabitatsAdaptationsZoo 101Locomotion (Grades K-2 only)Conservation and Endangered Species (Grades 3 and up)How many people will participate in the program? (more than 30 may require additional programs)*What is the age range of the participants?* PreSchool Kindergarten Grades 1-2 Grades 3-6 Grades 7-8 High School Adult group What payment method do you plan to use to pay for your program?* Cash Check Credit Card Purchase Order Additional questions or notes for Zoo staff?
