Form Builder

First Name

Last Name

Email

Personal Email

*Some school districts have strong firewalls. Please include a personal e-mail as a back up.

Phone Number

Grade Level

Number of Students

School Name

School Street Address

City

Province

Postal Code

Tell us what topic(s) you would like the geologist to cover during the presentation

Preferred Date(s) and Time of Day

Please list them in order of preference.

Special Notes

AV Requirements

This program will require access to the internet and the ability to receive and transmit both audio and video.