VIRTUAL Zoo Adventure Program Request VIRTUAL Zoo Adventure Request Form Please fill out the following form to request a virtual, ONLINE Zoo Adventure program. 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 2 weeks 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 Please list your top two date choices (please use + to add dates)* Desired start time, programs must take place after 8am MST-AZ*Please select a time for your program. What TIME ZONE are you in?Program topicHabitatsAdaptationsZoo 101Locomotion (Grades K-2 only)Conservation and Endangered Species (Grades 3 and up)Animal Food and Nutrition (Grades 3 and up)Animal Health Care (Grades 3 and up)How many people will participate in the program?*Will some participants be joining us separately from their own home? YES No, we will all be watching together from one computer/tablet How many additional people will the link be given to so that they can watch from their own home?What is the age range of the participants?* PreSchool Kindergarten Grades 1-2 Grades 3-6 Grades 7-8 High School Adult group Virtual Program Safety A teacher or school representative must be present for the duration of the program.By checking this box, I understand that a teacher or school representative MUST be present for the entire virtual program. Available Technology - please select an option for video AND audio Yes, I will have a webcam and can share my video during the program. No, I do not have a webcam. Yes, I can share audio through my computer, laptop or other microphone. No, I will not be able to share audio during the program. I do not have access to a computer, please contact me to discuss options Please assist us in planning for your program by checking which technological features will be available to you during your program. (Having a webcam and/or microphone is preferred to improve the interaction between educators and students but not required). What payment method do you plan to use to pay for your program?* Check Credit Card Purchase Order This program is for a school/youth group and therefore the fee is covered by Zoo grants Payment or PO must be received before the program start date. Title 1 School YES NO Does your school receive Title 1 funding? This will help us determine grant funding. Additional questions or notes for Zoo staff?