School/Organization:*

	County:

	MAILING ADDRESS*
	Street   City   State   Zip

	CONTACT INFORMATION*
	Lead Contact Name   Work Phone   Alternate Phone   Fax   Email

	TYPE OF PROGRAM Please identify your program (s) of interest. More detailed information is available on the web at uncw.edu/marinequest or by calling us at 910.962.2460.
	Marine Explorers (Half-day classroom and laboratory activities and tours at the UNCW Center for Marine Science)    Costal Encounters (Grades 3-12) (A full day of classroom, laboratory and field activities based out of the UNCW Center for Marine Science)    Costal Encounters Extended Day (Includes our Costal Encounters program with an additional UNCW campus experience, tour & dinner)    Costal Encounters 2nd & 3rd Day Options (Allow for groups to enhance their learning experience through continued laboratory and field activities)    Coast to Classroom (Five hours of interactive presentations or science center rotations delivered at your school by MQ environmental educators)    Boy Scouts Program (Full-day)    Girl Scouts Program (Full-day)    Customized Program    Service Learning Opportunities

	GROUP INFORMATION
	Grade:   Number of Participants:   Age Range of Participants:   Number of Classes (if applicable):

	PREFERRED PROGRAM DATES Depending on your program, scheduling may be based on facilities availability. Please provide a minimum of three possible dates in order of preference.
	1   2   3

	HOW DID YOU LEARN ABOUT THE MARINEQUEST PROGRAM?
	Direct Inquiry    Email    Flyer/Brochure    School Advertisement    Website    Word of Mouth    Past Program    Other, please specify