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2017 PhUn Week Event Planner Form
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1.
APS Member Coordinator First Name
(Required.)
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2.
APS Member Coordinator Last Name
(Required.)
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3.
APS Member Email Address
(Required.)
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4.
Institution
(Required.)
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5.
Department
(Required.)
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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.
(Required.)
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7.
Shipping Address Line 2
(Required.)
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8.
Shipping Address City
(Required.)
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9.
Shipping Address State
(Required.)
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10.
Shipping Address Zip Code
(Required.)
11.
Phone Number
This phone number will be used just in case FedEx has a delivery issue.
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12.
Date(s) of your visit to the classroom(s)/ school(s):
(Required.)
Monday November 6, 2017
Tuesday November 7, 2017
Wednesday November 8, 2017
Thursday November 9, 2017
Friday November 10, 2017
Other.
If you select"other", for your Classroom visit, it must take place before March 1. Indicate the day(s) you will visit the classroom. If your event is scheduled after March 1, you need to complete a K-12 Outreach Event Planner.
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.
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15.
Lead Teacher Coordinator First Name
(Required.)
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16.
Lead Teacher Coordinator Last Name
(Required.)
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17.
Lead Teacher Email Address
(Required.)
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18.
Lead Teacher/Coordinator School Name
(Required.)
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19.
School Address
(Required.)
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20.
School City
(Required.)
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21.
School State
(Required.)
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22.
School Zip Code
(Required.)
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.
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25.
Please specify the
NUMBER OF STUDENTS IN EACH GRADE LEVEL
that will be participating in your PhUn Week event.
(Required.)
Pre-K/Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
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26.
TOTAL NUMBER of STUDENTS Participating
(Required.)
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27.
TOTAL Number of Physiologist/Scientist Presenters (this will determine total number of shirts and patches sent in your shipment).
(Required.)
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28.
TOTAL NUMBER of Teachers (this will determine total number of shirts and patches sent in your shipment).
(Required.)
