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Science Speakers Volunteer Application

First Name:

Last Name:

Home Address:

Street:

City:

State:

Zip:

Home Phone:

Mobile Phone:

Primary Email:

Secondary Email:

It is best to contact me by (please choose)

Email

Phone

Are you employed?
Yes
No

Place of Employment:

Job Title:

Work Address, City, State/Zip:

Work phone and extension:

Confidentiality Statement
I understand that the volunteer screening process includes both criminal background checks and reference checks. I give permission to have the results of these checks shared with placement sites considering my involvement as a volunteer.
Yes
No

I am volunteering to visit a school and will make:

1 presentation (45 minutes)

2 presentations (90 minutes)

School is in session between 8:30a.m. and 3:03p.m., I am available:

Mornings (time)

Afternoons (time)

Any time

Students learn best and are more engaged when speakers combine experiments or hands on learning with their presentation. Will you be able to include or provide experiments and/or hands on learning?
Yes
No

The occupation or interest I will speak about is:

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