Request for Chemistry Outreach Activities
Before submitting the completed form, please note the following:
•	The safety of the participants is paramount. Laboratory experiments require long pants, shoes that completely cover feet, and socks. Midriffs may not be exposed. Safety glasses will be provided and must be worn at all times during an experiment.
•	Photographs of participants may be taken during outreach activities and used by the university for promotional purposes, online or in print. Participants not wishing to be photographed must inform us prior to the start of the outreach activities.
•	Your application will be processed as quickly as possible, but due to time, space, resource, or personnel limitations, we may be unable to provide the activities requested.
Contact name
     	Email
     	Phone:      
Fax:       	
Organization name and address
     	
Requested activities
         Presentations:     states of matter presentation with dry ice/liquid nitrogen
                                              glassblowing demonstration
                                              other (please specify -       ) 
         Hands-on experiments
         Science fair judges	
Group information
        Number of participants:      
        Grade and age range of participants:      
        Period of time requested:      
        Dates requested:      	
Other comments
     	
Send the completed application and any questions or comments to chemoutreach@uwo.ca. Please include Outreach Request and the name of your organization in the subject line.
Thank you for your interest in our outreach program.