Please complete the following form to submit a request to the GOT Space team. If you have any questions, please contact the team by sending an email to GOTspace@gatech.edu Requester InformationName* First Last Email* Phone number where we can contact you*Alternate phone number*Best day / time(s) to call you* ex. What time is your planning period? Name of School / Museum / Youth Program* School / Museum / Youth Program Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code School / Museum / Youth Program Website Outreach Request DetailsType of Outreach Requesting*Select oneLarge Group PresentationSmall Group PresentationSTEM "Night" eventRocket Team visitRemote "Skype" presentationOtherIf Other, please explain Grade Level(s)* K-2nd grade 3rd grade 4th grade 5th grade 6th grade 7th grade 8th grade 9th grade 10th grade 11th grade 12th grade What grade level(s) are the audience?Number of students*Estimate of how many students would be participating in outreach event.STEM Presentation topic requested* Any presentation The STAR of our World Mars: Past, Present, and Future How to make a Planet... with Life! The International Space Station Space Telescopes: Searching for Other Worlds How the Milky Way Works Looking at Galaxies in Radio How to Measure Distances in the Universe Black holes How Galaxies and Their Black Holes are Connected Ecology Other Check "Any presentation" if you are completely flexible, or check those that you would be interested in/willing to host. If Other presentation is selected, please explain How many rotations of each presentation are desired?* Each presentation is roughly 45 minutes (30 minutes for the interactive slide show and 15 minutes for questions). Four presentations is the max we expect our presenters to do in one day. We recommend smaller groups, but we can accommodate assemblies or even multiple visits if necessary.Proposed Date and Time* We will do our best to accommodate your requested date, however please recognize that our STEM ambassadors are busy college students and some flexibility is necessary.Please give us an idea of the supplies you have. Check all that apply.* Projector, blank screen or wall, and dark room Speakers with laptop plug-in Computer with flash drive plug-in Extension Cord Microphone Other None of the above If you don't have some of these supplies, we'll try to find some of our own to bring.If Other, please explain I understand that GOT Space STEM Ambassadors are not employees of any government agency, and I take responsibility for them on school grounds.* Yes If you have any other thoughts or concerns about your GOT Space STEM Ambassador's visit, please indicate below.NameThis field is for validation purposes and should be left unchanged.