Request a Student Workshop - Pennsylvania Society for Biomedical Research

Student Workshop Request

In order to efficiently coordinate and schedule a student workshop for your class, please provide us with as much information as you currently have available at this time. Please enter "TBD" for pieces of information you do not have yet.

Name*

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Email Address*

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Confirm Email Address*

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Teacher Cell Phone Number (xxx-xxx-xxxx)*

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School Name*

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School Address*

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School City, State, Zip*

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Grade(s) of Attending Students*

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Subject(s) of Attending Students*

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How did you hear about PSBR student workshops?*

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Have you participated in a PSBR student workshop in the past?*

YES

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# of Students you expect to attend the workshop*

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# of Teachers/Chaperones you expect to attend*

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Preferred Workshop Location*

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Arrival Time (What time can students arrive at the chosen location in the morning)?*

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Departure Time (What time must students depart the location in order to arrive back at school)?*

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Dietary Restrictions (Does anyone attending have any special dietary needs? PSBR will provide free lunches)*

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Possible Dates for Workshop*

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Percent of students that identify as: male, female, neutral, or other

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Percent of students that identify as: White, Black, Hispanic or Latino, Asian, American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, or Other

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Percent of students classified as Title 1

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Additional Comments/Questions

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