Program Request Form What would you like to book today? Please check all that apply * Traveling Program Virtual Program 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 * Organization Address * Organization Address Organization Address Organization Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Organization Phone * 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 Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe 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 Science at Home Kit Program 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: $295 plus travel charges, $250 for 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 * 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) Make it Magnetic (3-PS2.B) 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)- Available Soon 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: $295 plus travel charges, $250 for 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: $500 per showCapacity: 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 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 * Science at Home Kit Programs Price:$475 per kit plus travel charges, $425 for 3 or more kits booked on the same day Capacity:25 participants per kit Length: 50 minutes Science at Home Kit Programs * Buzzy Bug Bots Color Changing Slime Dinosaur Claws Food Chemistry Paper Circuit Greeting Cards # of Programs Requested * # of Participants per program * Total # of participants * Preferred times of Programs * Virtual Program Logistics Which video communication platform will you be using? * Zoom Google Meet / Google Classroom OtherOther The Connecticut Science Center uses Zoom and Google Meet as their main video communication platforms. If you require use of another platform, we will follow up with you to discuss other options. STEM Career Showcases utilize a live YouTube stream in place of Google Meet and Zoom. How will your students be participating in this program? * In the classroom, as one group At home, individually Combination of in the classroom & at home Virtual Program Options What type of virtual program would you like to book? * Classroom & STEM Career Programming Enrichment Programming Science at Home Kit Programming Girl Scout Programming Classroom & STEM Career Programming Pricing: $200 per program Capacity: Up to 25 students per program Length: 45 minutes Program Requirements: • Computer to stream the live program • WiFi connection • Speakers & microphone capabilities (can be through a laptop, desktop, or webcam) • Screen to share the computer with a larger audience (optional) Teachers will be provided with student handouts — no additional materials are needed. Classroom & STEM Career Programming * Animal Appetites (NGSS K-LS1.C) The Secret Life of Plants (NGSS 1-LS1.A) Shifting Sediments (NGSS 2.ESSA.2) Crash Lab (NGSS 3-PS2.A) Making Waves (NGSS 4-PS4.A) A Chem-Mystery (NGSS 5-PS1.B) Refraction Action (NGSS MS-PS4.B) STEM Career Showcase (Middle & High School) 2022 STEM Career Showcase Dates: • Friday, March 25, 2022 • Tuesday, May 3, 2022 • Friday, June 3, 2022 • Friday, November 4, 2022 • Tuesday, December 6, 2022 Enrichment Programming Pricing: $200 per program Capacity: Up to 25 students per program Length: 45 minutes Program Requirements: • Computer to stream the live program • WiFi connection • Speakers & microphone capabilities (can be through a laptop, desktop, or webcam) • Screen to share the computer with a larger audience (optional) Enrichment Programming * Picnic Caper: A Fur-ensic Mystery (Grades K-2) Creative Creatures (Grades K-3) Mission: Space (Grades 3-5) Shocking Science (Grades 3-5) Extreme Air (Grades 4-8) Global Soundscapes (Grades 4-8) Enrichment Kits Our Science at Home Kit experience is now available for group bookings! Receive all of the materials needed for your entire classroom, youth group, or after-school program to participate in exciting hands-on science activities with the help of our STEM education team. Choose between a live, interactive, one-hour class or pre-recorded instructional video to follow along at your leisure, and upgrade your experience to Enrichment Kits Plus for enhanced materials and activities. • One box serves up to 25 participants. • Add-on materials can be purchased for an additional fee in increments of 10 participants. • Recommended for participants ages 6-12. • All the necessary supplies are included to complete all activities. • Shipping (within the United States) is included with purchase. • LIVE Experiences will be booked at a mutually agreed upon date and time between the Connecticut Science Center presenter and the purchaser. • Programs must be booked at least 2 weeks in advance of the requested date to allow for shipping. • Listed activities are subject to change without notice due to material supply shortages or other unforeseen circumstances. Canceled activities will be replaced with something of equal or greater value. Enrichment Kit Programming * Enrichment Kit Enrichment Kit PLUS Bundle Enrichment Kit Live Experience Pricing: $250 per program — all materials included Capacity: Up to 25 students per program Length: 60 minutes Pre-recorded Session Pricing: $175 per recording — all materials included Capacity: Up to 25 students per program Length: varies by program This is the original Science at Home Kit experience for larger groups and includes either a LIVE session with one of our STEM Educators or a pre-recorded session allowing you to complete the activities at your own pace. Both options include all the materials needed to conduct the experiments. Would you like a Live or Pre-recorded program? * Live Experience Pre-recorded Session Program Options * Color Changing Slime Paper Circuit Greeting Cards Dinosaur Claws Would you like to add supplies for an extra 10 participants for $90? * Yes No Enrichment Kit PLUS Live Experience Pricing: $350 per program — all materials included Capacity: Up to 25 students per program Length: 60 minutes Pre-recorded Session Pricing: $250 per recording — all materials included Capacity: Up to 25 students per program Length: varies by program We took the original Science at Home Kit experience for larger groups, and we enhanced it with bigger and bolder experiments and upgraded supplies to complete those experiments. This version, like the original, includes either a LIVE session with one of our STEM Educators or a pre-recorded session allowing you to complete the activities at your own pace. Both options include enhanced materials needed to conduct the experiments. Would you like a Live or Pre-recorded program? * Live Experience Pre-recorded Session Programs Options * Food Chemistry (STEM in a Box PLUS) Buzzy Bug Bots (STEM in a Box PLUS) Mummies of the World (STEM in a Box PLUS) Would you like to add supplies for an extra 10 participants for $90? * Yes No Enrichment Kit Bundle Pricing: $500 per bundle — all materials included Capacity: Up to 25 students per program Length: 60 minutes for Live Experience, time varies for Pre-recorded Sessions Get the best of everything! We will include one (1) live experience (from the Plus collection) and two (2) pre-recorded sessions (from the original collection). Please select a Live Experience Plus program: * Food Chemistry Buzzy Bug Bots Mummies of the World Please select 2 Pre-Recorded programs: * Color-Changing Slime Paper Circuit Greeting Cards Dinosaur Claws Would you like to add supplies for an extra 10 participants for $90? * Yes No Girl Scout Programming Pricing: $200 per class Capacity: Up to 25 scouts per class Length: 45 minutes Availability: Monday-Friday, 9am-6pm. Must be booked at least 2 weeks in advance Program Requirements: • Computer to stream the live program • WiFi connection • Speakers & microphone capabilities (can be through a laptop, desktop, or webcam) • Screen to share the computer with a larger audience (optional) Girl Scout Programming * Junior - Detective Brownie - Fling Flyer Virtual Program Logistics First Choice Date * 2022 STEM Career Showcase Dates: • Friday, March 25, 2022 • Tuesday, May 3, 2022 • Friday, June 3, 2022 • Friday, November 4, 2022 • Tuesday, December 6, 2022 Second Choice Date * Third Choice Date * How many classes would you like to book? * 1 2 3 4+ How many classes would you like to book? * If you are booking for yourself, and other educators, please include their name(s) and email(s) below. How would you like to schedule your classes? * On the same day On separate days # of participants (per program) * Preferred Start Time of Program(s) * Day of Contact Phone Number * Please list any special requests: Science at Home Kit Shipping Info Please fill out the mailing information below Mail to the attention of: * Mailing Address * Mailing Address Mailing Address Mailing Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal 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: * If you are human, leave this field blank. Submit