Name of High School: *
School Location (City and State): *
Class/Group Name (i.e. Biology Class, Chemistry Class, AP group, etc.): *
Class Level (i.e. 9th grade, mixed grades, 11th and 12th grades): *
Does your class/group consist largely of underrepresented groups in the sciences and engineering? Or of students who have few school-provided science enrichment opportunities? If yes, please explain.:
Does your school currently have a Nanotechnology or similar type of program?
Do you anticipate any problems with arriving by 9:30am and departing at 2:00pm: * Activities will be located in buildings close to the intersection of 33rd St. and Walnut St., on the University of Pennsylvania campus. Yes No Other Comments:
If your group is invited to attend, do you foresee any issues with attending (committing to come and attending)? * Yes No Other Comments:
Has Your School Ever Participated in Past NanoDay Events?: * Yes No If yes, what year did they last participate?
First Name of Primary Teacher: *
Last Name of Primary Teacher: *
Primary Teacher’s Email Address: *
Primary Teacher’s Cell Phone Number: *
Note: We require a cell phone number in case of emergency on the day of the event. All other primary correspondence will be done through email.
Total Number of Teachers/Chaperones Attending: * —12345
Additional Names of Teachers/Chaperones:
Number of Participating Students: *
