Math/Science Equipment/Resource Request

Math/Science Equipment/Resource Request
Type of school or name of facility or agency making request*

Public SchoolParochial SchoolOther
Building-Public
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Building-Parochial
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Name*

First NameLast Name
E-mail*

Confirmation Email
Phone Number*

Area CodePhone Number
Item #1*
Item #2
Item #3
Item #4
Item #5
Approximate # of students to use the item(s)*
Approximate hours item(s) will be used by students*
Grade Level (Check all that Apply)*
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Send and Return Delivery Dates
Send and Return Delivery Dates
Pick up and Drop off Dates*
Please contact JCISD Math/Science support secretary with any questions or concerns.

Becci Clark, 517-768-5251, rebecca.clark@jcisd.org
I understand that I am responsible for returning item(s) in the condition it was(they were) received, minus some of the consumables, or could be charged a replacement fee. This equipment is a shared resource across the county. PLEASE keep equipment safe from food, drink, and other possible contaminants.*

YES
Should be Empty: