Middle School Outreach Interest Form

Middle School Outreach Interest Form

Middle School Outreach Interest Form

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First Name:
Last Name:
Legal Name: (If different from above)
Birthdate: (mm/dd/yyyy)
Work Email
Personal Email:
Street Address:
City:
State:
Zip:
Phone:
LinkedIn Profile:
Department or Company: (e.g. Chemistry)
Lab Group: Please include professor first and last name(if applicable)
Please check this box if your research of lab is affiliated with the Berkeley Lab:
Title:	Undergraduate Student Graduate Student Postdoctoral Fellow Visiting Scholar
Other Title:
Expected Graduation Year: (if applicable)	2027 2028 2029 2030 2031 2032
Gender: (collected for grant reporting purposes only)	Male Female Non-Binary Prefer not to say
Race / Ethnicity: (collected for grant reporting purposes only) (select all that apply: hold down 'Ctrl' on a PC or 'Command/Apple' on a Mac)	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander Hispanic / Latino White Mixed Race Other Prefer not to say
Other Languages Spoken (besides English): (select all that apply: hold down 'Ctrl' on a PC or 'Command/Apple' on a Mac)	Spanish Mandarin (Chinese) American Sign Language Cantonese (Chinese) French German Korean Japanese Tagalog Greek Arabic Italian
Grade level(s) you would like to work with:	6th 7th 8th
CRS sometimes gets requests from teachers for other kids of scientist volunteer support. Please let us know if you are interested in any of these other types of volunteering. (select all that apply; hold down 'Ctrl' on a PC or 'Command/Apple' on a Mac)	Developing a New Lesson General Outreach & Science Demos Judging Science Fairs
Do you have any experience working with students who have special needs (e.g., ADHD, learning disability, autism)? Please describe:
Please share additional information about yourself to better match you with your student groups! Please include hobbies, interests, and life experiences that students may relate to. (This is also the place to indicate a preference for a lab period or if you would like to participate in multiple lab periods).
How did you hear about the Be A Scientist program? (select all that apply)	Friend/Colleague Email from Department/University Student Group Web Search Your PI/advisor Flyer Social Media Other

CRS Photo Policy: To document our work supporting science education for the community and funding agencies, CRS/BASIS at times take photos and/or videos of our programs in action. We do not include volunteer or student names when publishing these images online or in print. By participating as a BASIS volunteer, you consent to CRS use of your photo or video image, unless you expressly opt out in writing. If you do NOT consent to CRS use of photo/video of you, please send a message to teach@crscience.org