Request a Program Education Program Request Form Group Name:*Type of Organization:*Primary Contact Name:*Contact Address: Street AddressAddress Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone Number:* - E-mail:*Preferred Contact Method:*PhoneEmailLocation for Presentation:*Presentation Address: Presentation AddrPresentation Addr Line 2Presentation CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPresentation StatePresentation Zip Code*Please note: For small groups (about 35 adults or 55 children), the Wildlife In Need Center currently has facilities for on-site education. If you wish to hold the program at WINC, please leave the Location Address blank.Estimated Attendance:*Preferred Date:*Preferred Time:* : AMPMAge/s of Group:Alternate Date:Alternate Time: : AMPMNumber of Programs*Select value123Please Choose the Type of Program:*Program TypeVirtual ProgramProgram featuring Animal AmbassadorsProgram with a PowerPoint PresentationProgram with Animal Ambassadors and a PowerPoint PresentationPublic Booth DisplayBirthday PartyPrivate Meet & GreetEstimated Length of Program (please specify length for each program if requesting more than one back-to-back):*20-30 minutes35-45 minutes50-60 minutes60-90 minutes1-3 hours (Public Booth Display)3 hours (Birthday Party)15-30 minutes (Private Meet & Greet)If you have selected a program with our educational ambassadors and/or a PowerPoint presentation, please select the program option(s) you would like.Please follow this link to our Program Options to find more details about what each option entails.Program Options:*General Program with a Variety of Educational AmbassadorsPowerPoint: The Wildlife In Need CenterPowerPoint: Call Before You KidnapOther (Please specify in Comments Section)If the program is at your location, which of the following items are you able to provide?*6'-8' TableProjector (PowerPoint Program Only)Projection Screen (PowerPoint Program Only)Laptop (PowerPoint Program Only)Pop-up Tent / Pavillion (outdoor)None of the AboveGirl Scouts - please list the pedal/badge your troop is working towards below:WINC Program History:First time scheduling a program with WINCI have scheduled a program in the pastThe Wildlife In Need Center's education program fees are listed on the Wildlife Education page on our website. The fees can be met monetarily, through in-kind collection of items from our wish list, or a combination of both. We also have an opportunity for groups to have the program fee to be covered partially or in full by means of a grant/scholarship that we offer through our center. The grant is called the Leslie Kiehl Education Program Fund. Please visit this page on our website for more information or to apply.Fee Agreement*I have reviewed the education program fees and I agree to pay the amount required for my program.I will apply for the Leslie Kiehl Education Program Fund.Comments:SubmitReset