Name of Organization * Example: School or Library, please include high school or elementary school Contact Name First Name Last Name Contact Email * Contact Phone * (###) ### #### I am Interested in Booking: Check all that apply A Field Trip to SCMELC Facility, Southold A Field Trip to Tiana Bayside Facility, Hampton Bays An Outreach Program at my school, library or other educational facility to conduct a program Programs of Interest * Check all that apply Discovery Tank Marine Science Careers Traveling Touch Tank Seahorse Biology and Conservation Intro to Marine Meadows (Eelgrass) ArtSea (Art/Science) Field Trip: Back to the Bays Day Field Trip: Salt Marsh and Estuary Ecology Field Trip: Barrier Beach and Dune Ecology Number of participants per class * Give the total number of students or participants that will attend the requested program. If entire grade, please describe total number of students and how many smaller groups/classes. Date 1 * Please list up to 3 possible dates and times for your requested program MM DD YYYY Time 1 * Hour Minute Second AM PM Date 2 MM DD YYYY Time 2 Hour Minute Second AM PM Date 3 MM DD YYYY Time 3 Hour Minute Second AM PM Additional Information * Include a personalize message with any other information you would like us to know. How did you hear about us? * Check all that apply Direct link to CCEMarineEastEnd.org CCESuffolk.org BacktotheBays.org Email CCE Staff Member Facebook Instagram Other Other If other, please describe how you heard about us here: Thank you! Someone will respond to your request shortly. Program Request Form
