APS Member Coordinator First Name

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* 1. APS Member Coordinator First Name

APS Member Coordinator Last Name

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* 2. APS Member Coordinator Last Name

APS Member Email Address

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* 3. APS Member Email Address

Institution

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* 4. Institution

Department

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* 5. Department

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.

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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.

Shipping Address Line 2

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* 7. Shipping Address Line 2

Shipping Address City

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* 8. Shipping Address City

Shipping Address State

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* 9. Shipping Address State

Shipping Address Zip Code

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* 10. Shipping Address Zip Code

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

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

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

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

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.

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* 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.

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

Lead Teacher Coordinator First Name

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* 15. Lead Teacher Coordinator First Name

Lead Teacher Coordinator Last Name

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* 16. Lead Teacher Coordinator Last Name

Lead Teacher Email Address

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* 17. Lead Teacher Email Address

Lead Teacher/Coordinator School Name

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* 18. Lead Teacher/Coordinator School Name

School Address

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* 19. School Address

School City

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* 20. School City

School State

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* 21. School State

School Zip Code

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* 22. School Zip Code

Please list the NAME(S) of any OTHER TEACHER(S) on team hosting the Physiologist presenters.

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* 23. Please list the NAME(S) of any OTHER TEACHER(S) on team hosting the Physiologist presenters.

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

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

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

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

TOTAL NUMBER of STUDENTS Participating

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* 26. TOTAL NUMBER of STUDENTS Participating

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

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

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

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

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