Southeastern Kentucky Project WILD Regional Service Center
Eastern Kentucky University
c/o Robert J. Miller
Memorial Science B-13, EKU
Richmond, KY 40475-3123
Phone (606)-622-2167
Fax:(606)-622-6181 or (606)-622-1020
E-MAIL: ELE1MILLER@ACS.EKU.EDU
Your Name:_________________________________________ SSN#________________________
Mailing Address:__________________________________________________________________
City:___________________________________ ZIP:____________ Phone:___________________
Date of Event:_________________________ Location:____________________________________
Facilitators: (Please include names and addresses of all facilitators, besides yourself)
_______________________________________________________________________________
_______________________________________________________________________________
Kind of Event: (Please circle one.)
a. workshop (4-16 hrs)
b. presentation (up to 4 hrs)
c. institute/course (more than 16 hrs)
d. other (please specify)__________________________________________________
Length of Time__________hours --- Number of Participants_____________________
Audience: (Please specify: i.e. teachers, administrators, etc..)
______________________________________________________________________
Specify what materials participants recieved:
a. Project Wild Activity Guide (copies distributed)________________________________
b. Project Wild Aquatic Guide (copies distributed)________________________________
c. Other (Please List)______________________________________________________
Monetary Requests:
a. $75.00 honorarium______________________________________________________
b. Travel, number of miles_____________, from _____________________ to ________________
c. Instructional Materials (small amounts available, reciepts identifying materials are needed.)
____________________________________________________________________

Back to the Southeastern Kentucky Project WILD Regional Office Homepage
Page developed with Netscape Navigator Gold 3.01
![]()