Teen Program Request Form Teen Program Request Form Thank you for requesting a Teen Program from the CT Science Center. Please fill out the information below to start the program request process. Organization Information Organization Name * Organization Address * Organization Address Organization Address Organization Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Organization Phone * 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 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) * Program Logistics Investigate! Career Academy Series: $325 per program, plus travel Teen Science Café: $2,000, plus travel Operation Artery: $315 per program, plus travel Includes a recommended event budget for the student to use to host a café event Requirements: We require access to an outlet and a screen to connect to for all programs. A school or program staff member must be present for this program. What type of program would you like to book? * Teen Science Café Investigate! Career Academy Series Operation Artery Workshop Other What grade level are your students? * Grades 6-8 Grades 9-12 Number of anticipated students * Teen Science Café requires meeting with one of our staff members for a minimum of 8 45-minute planning sessions. Please select your preferred day of the week for these sessions below. Planning Session Preference * Tuesday Wednesday Thursday Date of the Café event * Series Options * Architecture and Design Genomics Environmental Science Biomechanical Engineering Sound Engineering Space OtherOther Please note that each topic requires two meeting times. Session Date 1 * Session Date 2 * Alternate Session Date 1 * Alternate Session Date 2 * How long would you like the program to run? * 45 minutes 60 minutes Preferred Date * Alternate Date * How long would you like the program to run? * 45 minutes 60 minutes Payment Information For questions regarding your program, please contact: teens@CTScienceCenter.org or 860-520-2123 For questions regarding your payment, please contact: reservations@CTScienceCenter.org or 860-520-2150 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
