Community Outreach Program Request Form

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Organization or Group name:

Group Leader/Contact:

Email: Phone:

Street Address:

City: Zip: County:

Program Location (if different from above):

1st Choice Date:  
2nd Choice Date:
3rd Choice Date:

Estimated Number of Program Participants:


Please Describe Program Participants (children, adults, families, student group, ages of children, etc.):

Do any participants have special needs of which the outreach educator should be aware?

Program Request
Oregon Rocks!
Engineer It! Exploring Ancient Technologies
Move Like a Mammoth

How did you hear about the MNCH outreach program?

 Additional Comments

Cost: Program fee for a Library Family Program is $110 plus travel expenses (mileage at $0.545/mile outside the Eugene/Springfield area and additional fee for overnight stay if necessary for program delivery). Fees for other community outreach programs will be determined based on specific program requests.