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 Susquehanna University
  

Reservation Form

THIS FORM MUST BE COMPLETED IN FULL TO HOLD EQUIPMENT AND VISIT DATES.

To schedule a visit or equipment loan:

  • Contact a SIM mobile educator to make requests and check availability.
  • Complete and submit the following form within one week to secure your reservation.
  • Please fill out all information, including course title, number of class periods, and how many students in each grade level.
  • If the form is not completed and returned on time, your reservation is not guaranteed (the equipment and/or dates may be given to someone else)
Name:    
First                         Last
School: 
School Phone:  () -  
E-Mail: 
Equipment/Experiment
Needed:

SIM Visit

Date:      
Month     Day        Year
Arrival Time: 
Subject: Bio  Chem  Phys
Course Title: 
Grade Level(s): 
(# of students in
each grade) 		   7             8            9           10          11          12
              
Class Periods:   1       2      3      4      5      6      7      8      9    10    11   
                                
# Groups per
Class Period: 
Number of Students: 
Number of Handouts: 


Drop Off Only*

Date Needed:      
Month     Day        Year
Arrival Time: 
Subject: Bio  Chem  Phys
Grade Level(s): 
(# of students in
each grade)		    7              8             9            10           11           12
              
Deliver to Location/Room # 
Class Periods:   1       2      3      4      5      6      7      8      9    10    11   
                                
# Groups per
Class Period:
Maximum 6 
Number of Students: 
Number of Handouts: 

*Please keep in mind that there will be a two week time limit to drop-off loans. Generally, Mondays will be set aside for mobile educators to drop off and pick up equipment.

 
 
Susquehanna University Last reviewed by Melanie Rohrbach
Courtney Thomas, Director, Science in Motion
©2002 Susquehanna University, Selinsgrove, PA 17870
Telephone: 570-372-4779 Fax: 570-372-2791