Embryology Equipment Reservation

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University of California Cooperative Extension 4-H Science Education Classroom Resources
4-H Embryology...An Eggciting Adventure

Embryology Equipment Reservation Request: for Placer and surrounding counties only.

On-line reservation requests must be made a minimum of 14 days in advance of the requested reservation date.

* = Required
Question	Response
Teacher and Student Information
* First Name
* Last Name
* e-mail
* Phone Number (with area code)
* School
* Type of School	Public School Private School Special Education Vocational Education Homeschool/ Alternative Magnet/ Specialized School Charter School
* Mailing/Street Address
* City
* State
* Zip Code
* Grade Level (check all that apply)	K 1 2 3 4 5 6 7 8 9 10 11 12 Post High School Not in School Special Education
* Most students in this class live on/in:	Farm Rural (under 10,000) Town (10,000-50,000) Suburb of City (<50,000) Central City (>50,000)
Gender Distribution of Students (must enter actual numbers, 0 if none)
* Boys
* Girls
Racial Distribution of Students (must enter actual numbers, 0 if none)
* Hispanic
* White
* Black or African American
* American Indian or Alaska Native
* Asian
* Native Hawaiian/Other Pacific Islander
Gender Distribution of Adult Teachers/Volunteers (enter actual numbers, 0 if none)
* Female
* Male
Ethnicity Distribution of Adult Teachers and Volunteers (enter actual numbers, 0 if none)
* Hispanic
* White
* Black or African American
* American Indian or Alaska Native
* Native Hawaiian/Other Pacific Island
Distribution of Youth Volunteers (youth teacher assistants or teachers)
Do you have youth assisting or teaching in the classroom?	Yes No
If yes, please indicate: Number of Youth, Gender and Ethnicity
Equipment and Egg Reservation Request PLEASE NOTE: All requests will be filled by first come first served and availabilty of equipment and eggs. Equipment is in heavy demand during spring months. You will be contacted within a few weeks of your reservation to confirm pick-up date. If you need an early confirmation contact the office at 530-889-7386.
* Reservation Date Requesting (mm/dd/yy)
* How many incubators?(There is a $10.00 rental fee for each)
* Do you wish to purchase fertile eggs? ($3.00 a dozen)	Yes No
What type of eggs?	Chicken Duck
How many dozen would you like? It is suggested to use one dozen per incubator, no more than two dozen per incubator.