Program Request Form What would you like to book today? Please check all that apply * Traveling Program Please Note: * Submitting this form will result in a booking. If you would like a quote, please reach out to the Reservation Center at outreach@ctsciencecenter.org or call us at (860) 520-2165 What type of group are you booking for? * School Group: Public/private PreK-12 school, or accredited early childhood program Youth Group: After School Program, Day care, Parks and recreation, Summer camps, Scout groups, etc PWD Group: Groups of persons with disabilities If your group does not fit into any of these categories please call the Reservation Center at 860-520-2150. We are happy to help! Organization Information Organization Name - If booking for an afterschool program, please include the name of the afterschool program. * Organization Address * Organization Address Organization Address Organization Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Organization Phone - If booking for an afterschool program, please only include phones that will be operated during the requested timeframe of your program(s). * Grade Level * Pre-K Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6-8 Grade 9-12 This does not apply to my group Your Information Title * Mr. Mrs. Ms. Dr. Mx. Name * Name First First Last Last Phone #1 * Phone Type #1 * Work Mobile Phone #2 Phone Type #2 Work Mobile Email * What is your title? * Educator Administrator Parent OtherOther Traveling Program Location Information Will the program be taking place at the address you entered in the Organization Info section? * Yes No Program Location Name Program Location Address * Program Location Address Program Location Address Program Location Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Specific Room Name or Room Number where the Traveling Program will take place: * Point of Contact (required) * Traveling Program Logistics First Choice Date * Second Choice Date * Third Choice Date * How many classrooms are you booking for? * What type of program would you like to book? * Classroom Program Exploration Program Pre-K Classroom Program Assembly Show Activity Station What grade(s) are you booking for? * K-2 3-5 6-8 9-12 Please select the grade band(s) that will be participating to view the program options. Pre-K Programs Price: $200 plus travel charges, $175 for the same program booked on the same day. Capacity: Up to 16 participants per session. Length: 30 minutes We require tables and chairs, access to water and electricity, minimum of 10 minutes between sessions, and 15 to 30 minutes for set up and cleanup Pre-K Programs * Bubble-ology Need for Seed Weather Wonders Wiggly Worms # of Programs requested * # of participants per program * Total # of participants * Preferred times of Programs * Classroom Program Options Price: $315 plus travel charges, $295 for two of the same program booked on the same day, $275 for three of the same program booked on the same day. Capacity: Up to 25 participants per session. Length: 45 minutes We require tables and chairs, access to water and electricity, minimum of 15 minutes between sessions, and 15 to 30 minutes for set up and cleanup K-2 Programs * Animal Appetites (K-LS1.C) On A Roll! (K-PS2.A,B) Habitats and Homes (K-ESS2.E) Sound Breakdown (1-PS4.A) Tricky Traits (1-LS3.A) Facts of the Matter (2-PS1.A) Pollen-Nation (2-LS2.A) Shifting Sediments (2-ESS2.A) 3-5 Programs * Crash Lab (3-PS2.A) All Eyes on Evolution (3-LS4.B) Storm Trackers (3-ESS2.D) Choose Your Chompers (4-LS1.A) Powerhouse (4-ESS3.A) A Chem-Mystery (5-PS1.B) 6-8 Programs * Biodiversity Explorers (MS-LS.A,C) Gene-ius of Taste (MS-LS3.A) Reason for the Seasons (MS-ESS1.B) Refraction Action (MS-PS4.B) Tectonic Travels (MS-ESS1.C) Mighty Electromagnets (MS-PS2.B) Horsin' Around with Evolution (MS-LS4.A) 9-12 Programs * Gene-ius of Taste (HS-LS1.A) Conserving the Cottontail (HS-LS4.C,D) # of Programs requested * # of participants per program * Total # of participants * Preferred times of Programs * Exploration Program Options Price: $315 plus travel charges, $295 for two of the same program booked on the same day, $275 for three of the same program booked on the same day. Capacity: Up to 25 participants per session. Length: 45 minutes We require tables and chairs, access to water and electricity, minimum of 10 minutes between sessions, and 15 to 30 minutes for set up and cleanup K-2 Programs * Playing with Polymers (Grades 1&2) Picnic Capers 3-5 Programs * Alchemy Lab Balance Bonanza Global Soundscapes Mission: Space Playing with Polymers Roller Coasters Sail Cars Toppling Towers Zip Lines 6-8 Programs * Roller Coasters Toppling Towers # of Programs requested * # of participants per program * Total # of participants * Preferred times of Programs * Assembly Shows Price: $600 per show. Capacity: Available for groups of 100 to 250 participants Length: 45 minutes We require 6'of 8' free standing tables and access to water and electricity. Please allow 45 minutes for set up and breakdown of program materials. Assembly Show Options * Extreme Air Global Soundscapes (Requires a Stage Screen and Sound System) The Science of Suds Is there a stage available? * Yes No # of requested Assembly Shows * Estimated # of children (per show) Estimated # of adults (per show) Total # of children and adults * Preferred times of Assemblies * Activity Stations Price: $250 per station per hour, plus travel. Ideal for larger events, Activity Stations are tabletop demonstrations and hands-on activities designed to engage groups of students or families in 5-10 minute walk up experiences. More than one station can be booked for an event. Please allow 45 minutes for set up and breakdown of program materials. What type of event are you hosting? * What is your anticipated attendance? * What is the duration of this event? * Which Activity Stations would you like to book? * Electricity Dry Ice Air Pressure Bubbles Polymers Optional: $50 fee for take-home materials * Yes No Total # of participants * Preferred start time of Stations * Payment Information Full payment is required prior to your program. If you are unable to make payment in advance, please contact the Reservation Center to make alternate payment arrangements. Virtual Programs: reservations@CTScienceCenter.org or 860-520-2150 Traveling Programs: outreach@CTScienceCenter.org or 860-520-2165 Is your program being funded by a grant? * Yes No Please indicate the grant name below: * Submit If you are human, leave this field blank.
