Equipment Checkout Form

Louisa County Extension Equipment Checkout Form

For a list of the educational kits available to check out with descriptions, go to https://www.extension.iastate.edu/louisa/content/educational-kit-check-out
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Organization*

4-H/Clover Kids Club
Requested date of kit pick-up (more than 2 weeks from now):*

MonthDayYear
Date
Requested date of kit drop-off:*

MonthDayYear
Date
Educational Kit Series Requested
Educational Kit Requested - Engineering is Elementary

Designing Alarm Circuits - ElectricityMaking Work Easier - Simple MachinesA Sticky Situation - Designing WallsDesigning Light Systems - Light
Educational Kit Requested - Art-Lit to Go!

Mistake to MasterpieceLines on SignsShape-o-SaurusColor CreationStunning SculpturesTouch-and-Feel TextureLots of Layers
Educational Kit Requested - STEM-Lit to Go!

BubblesCurious CandyHealthy HeartsInventor's HatJumping BeansLots of LightPopping PopcornRoller CoastersSunny SunshineSuper SledTerrific TreesWonderful Wind
Educational Kit Requested - STEM-Lit to Go! Iowa

A Chair for BearBlast OffCode Across IowaHour at the FairMarvelous MarshmallowsMunching MysteriesScream for Ice CreamSound All AroundSuper ShapesTake a ChanceTricky TowersWonders of Nature
Educational Kit Requested - Steam'n Through the Seasons

Apple'liciousPumpkin ExplorationScurrying SquirrelsGingerbread TimeSnow SpectacularGifts From the HeartTrapTasticBitty BunniesSensational SeedsDirt-N-WormsSummer CelebrationsMake a Splash
Educational Kit Requested - Cooking

Kids in the KitchenBooks for Cooks
Educational Kit Requested - Computer Science

Dash & Dot RobotsBee-BotsGame Changer
Educational Kit Requested - Agriculture

Chick HatchingFuture Vet Toolkit
Educational Kit Requested - Other

NASA Astro CampKitchen ScienceInvent STEMiPad Lab
How many youth do you anticipate utilizing the kit materials & what grade level(s)?*
I understand that if the kit materials are not returned in working order that I will be billed for replacement costs.*

Yes, I understand
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Notes and Questions you have:
I, the undersigned, do hereby agree to the terms and conditions of the Iowa State University Extension and Outreach, Louisa County kit loan policy and agreement. I understand that by signing this document, I acknowledge reading the policy and will be held personally responsible for any damage, loss, or destruction of the equipment while it is in my possession.
Signature*

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Louisa County Extension Equipment Checkout Form