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.)