SCOPE-0N-A-ROPE Checkout Form

Workshop Request Form

LSU-HHMI Scope-On-A-Rope Program

Tab through the shaded boxes to fill in each field. Submit your completed form to the SOAR Program Coordinator (see contact information at bottom of page).

Name School

School Address City Parish

Phone number (best contact number) Email

Requested workshop dates:

1st choice 2nd choice 3rd choice

Workshops can be from 2-6 hours in length. What time is best on the dates listed above?

Time preference (indicate starting and stopping time)

Who will attend this workshop?

Number of teachers Grade level(s) Subject area(s)

Where will the workshop be held?

What technology do you have available at the site of the workshop? Check all that apply and indicate the number of each in the box after each item available.

video projector ( )

television monitor ( )

computer(s) with ability to install software ( )

Scope-On-A-Rope ( )

other type of hand-held microscopes (indicate type and amount: )

Do you have any other requests? (topics covered, type of scope preferred, etc.?)

**All workshops require approval from a school principal or supervisor.**

Have you received approval from your supervisor to hold this workshop?

Supervisor’s contact information:

Name Phone Email

Dr. Sheri Wischusen

LSU-HHMI Scope-On-A-Rope Program Director

LSU College of Science

336 Hatcher Hall, Baton Rouge, LA 70803

Ph: 225-578-0405 Fax: 225-578-7627