Advancing Science

Equipment Loan Equipment Use Request Form

 

Instructions:

  • Please complete all fields.
  • Please complete ONE form for EACH visit.
  • To submit multiple requests, click your browser's "Back" button, change all necessary information, and click "Submit" again.

TEACHER INFORMATION:  
Teacher Name:
School Name:
E-Mail Address:
Work Phone:
Home Phone:
FAX:
Best Time to Call (Be Specific):
Grade(s) Taught:
(only those involved in this loan)
Subject:
(only the subject involved in this loan)
Biology Physical Science
Chemistry Earth Science
Physics General Science
Other:  
Will any teachers other than yourself be participating in this Equipment Loan? YES NO
If yes, please list the other teacher(s):
VISIT INFORMATION:  

Date(s) Needed:

Please provide several possible dates and list in order of preference.
Lab(s) Requested:
Name of Other Activity:
List any specific equipment you would like to borrow instead of (or in addition to) a specific lab:
CLASS INFORMATION:  
Best time to drop off this equipment:
TOTAL STUDENTS using the equipment:
TOTAL CLASSES using the equipment:
Number of students in your LARGEST CLASS:
Are any of the classes using this equipment Advanced or AP classes? YES NO
If yes, number of Advanced/AP STUDENTS:
If yes, number of Advanced/AP CLASSES:
OTHER INFORMATION:  
Would you like this activity sent to you? YES NO
Are you willing to have students evaluate the Advancing Science program? YES NO
Briefly describe your plans for using this equipment, especially the role of the Mobile Educator:
Comments/Questions For Advancing Science:

Please select "I Agree" below to indicate that you have read the guidelines for Van Visits/Loans
in the Advancing Science Primer and agree to comply to the rules and regulations therein.
To read these rules and regulations, click here.

Effective August 2006, Advancing Science is charging service fees to help defray the cost
of our services, please refer to our fee structure for more details.

I Agree I Disagree

Information will be sent to:
Lesa Bird, Jack Sipe and Valerie Stone
Gettysburg College
300 N. Washington St.
Advancing Science Box 392,
Gettysburg, PA 17325

Phone: 717-337-6150
FAX: 717-337-6157
e-mail: advancingscience@gettysburg.edu

 

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