Presentation Request Form | Insect Ambassadors: UW-Madison, Dept. of Entomology

Insect Ambassador Visitors

Insect Ambassador Online Request Form

1.	Contact Information
	Name:
	E-mail:
	Phone:
2.	Name of school or affiliation:
3.	Street address:
	City:
	State:
	Zip code:
4.	Please indicate the age group or class grade.
	Age group:
	Class grade:
5.	Please request a date and time (if possible, please indicate 2 or 3 to choose from).
		Date (mm-dd-yyyy)	Time
	First choice:
	Second choice:
	Third choice:
	Want to see what dates are taken? Click here for our presentation calendar.
6.	Number of presentations for the date requested:
	Note: If you would like to request presentations for more than one day, please fill out a separate form for each day that you are requesting presentations.
7.	Estimate number of students for each presentation:
8.	Directions to presentation site:
9.	Special requests/comments:
10.	Donations to Insect Ambassadors help us feed the live insects, maintain insect cases, and cover our travel expenses.
	Please check one of the following: I will pay the $1 fee per student. I would like information about donations for groups of more than 50 students.		Yes Yes

Thank you for your interest in Insect Ambassadors. We will contact you in the next couple of days to confirm your request. If you prefer us to contact you at a different email address or phone number than listed above, please let us know how best to contact you in Section 9. Please make checks payable to "Insect Ambassadors" and have the payment ready at the time of the presentation. Thanks again! Insect Ambassadors