Your Name

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* 1. Your Name

Your Contact Information:

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* 2. Your Contact Information:

Program/Organization name:

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* 3. Program/Organization name:

Program Location Information:

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* 4. Program Location Information:

Please list all of the places your organization serves: (ex.- schools, community organization, etc.)

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* 5. Please list all of the places your organization serves: (ex.- schools, community organization, etc.)

Total # of youth served:

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* 6. Total # of youth served:

Do you currently use STEM activities with your youth?

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* 7. Do you currently use STEM activities with your youth?

T