* 1. APS Member Coordinator First Name

* 2. APS Member Coordinator Last Name

* 3. APS Member Email Address

* 4. Institution

* 5. Department

* 6. Shipping Address Line 1
This address will be used to ship your materials to the APS member ONLY. Please no P.O. boxes as everything is shipped via FedEx.
ALL addresses should be shipped to a business, we will not ship to a residential address.

* 7. Shipping Address Line 2

* 8. Shipping Address City

* 9. Shipping Address State

* 10. Shipping Address Zip Code

* 11. Phone Number
This phone number will be used just in case FedEx has a delivery issue.

* 12. Date(s) of your visit to the classroom(s)/ school(s):

* 13. Please include the NAME(S) and POSITION(S)/ACADEMIC LEVEL(S) for any other physiologist/scientist presenter(s) on your team. We must have these names in order to send shirts and patches in your shipment.

* 14. Please include the EMAIL(S) for any other physiologist.scientist presenter(s) on your team. Please use a semi-colon between each email.

* 15. Lead Teacher Coordinator First Name

* 16. Lead Teacher Coordinator Last Name

* 17. Lead Teacher Email Address

* 18. Lead Teacher/Coordinator School Name

* 19. School Address

* 20. School City

* 21. School State

* 22. School Zip Code

* 23. Please list the NAME(S) of any OTHER TEACHER(S) on team hosting the Physiologist presenters.
We must have these names in order to send shirts and patches in your shipment.

* 24. Please list the ADDRESS(ES) of any OTHER TEACHER(S) on team hosting the Physiologist presenters.

* 25. Please specify the NUMBER OF STUDENTS IN EACH GRADE LEVEL that will be participating in your PhUn Week event.

* 26. TOTAL NUMBER of STUDENTS Participating

* 27. TOTAL Number of Physiologist/Scientist Presenters (this will determine total number of shirts and patches sent in your shipment). 

* 28. TOTAL NUMBER of Teachers (this will determine total number of shirts and patches sent in your shipment).

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