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
If your group is invited to attend, do you foresee any issues with attending (committing to come and attending)? *
Yes No Other
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: *