2017 PhUn Week Event Planner Form Question Title * 1. APS Member Coordinator First Name Question Title * 2. APS Member Coordinator Last Name Question Title * 3. APS Member Email Address Question Title * 4. Institution Question Title * 5. Department Question Title * 6. Shipping Address Line 1This 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. Question Title * 7. Shipping Address Line 2 Question Title * 8. Shipping Address City Question Title * 9. Shipping Address State Question Title * 10. Shipping Address Zip Code Question Title * 11. Phone NumberThis phone number will be used just in case FedEx has a delivery issue. Question Title * 12. Date(s) of your visit to the classroom(s)/ school(s): 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. Question Title * 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. Question Title * 14. Please include the EMAIL(S) for any other physiologist.scientist presenter(s) on your team. Please use a semi-colon between each email. Question Title * 15. Lead Teacher Coordinator First Name Question Title * 16. Lead Teacher Coordinator Last Name Question Title * 17. Lead Teacher Email Address Question Title * 18. Lead Teacher/Coordinator School Name Question Title * 19. School Address Question Title * 20. School City Question Title * 21. School State Question Title * 22. School Zip Code Question Title * 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. Question Title * 24. Please list the ADDRESS(ES) of any OTHER TEACHER(S) on team hosting the Physiologist presenters. Question Title * 25. Please specify the NUMBER OF STUDENTS IN EACH GRADE LEVEL that will be participating in your PhUn Week event. 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 Question Title * 26. TOTAL NUMBER of STUDENTS Participating Question Title * 27. TOTAL Number of Physiologist/Scientist Presenters (this will determine total number of shirts and patches sent in your shipment). Question Title * 28. TOTAL NUMBER of Teachers (this will determine total number of shirts and patches sent in your shipment). Next