Teacher Intake Form

Lower Columbia Estuary Partnership Teacher Intake Form

School Name *

Grade *

Total number of participating students *

Which goals or interests do you hope to achieve through our education program? Check all that apply

Science enrichment
Environmental stewardship
Positive outdoor experience
STEM career exposure
Classroom/school community building
Other (please list below)

Other goals or interests:

This program is offered free of charge thanks to the generous support of our funders. To ensure future funding, you may be selected to complete the following tasks: administer a pre or post-program survey to your students (approx. 15 minutes) and complete a program evaluation (approx. 10 minutes) *

I agree

Would you like to request transportation reimbursement (based on availability) *

Yes
No

Lead teacher information:

First Name *

Last Name *

Email *

Phone *

Are there students in your class that cannot be photographed? *

Yes
No

Will students in your class require accommodation to participate in this program? A typical field trip involves walking 2 miles on uneven terrain.

Mobility adaptive field trip activities
Receive classroom/field trip materials in advance for English language learners
Other (please list below)