LEx Box Form

LEx Box Borrowing Form

Please fill in this form in order to borrow one of the LEx boxes from the Physics and Astronomy Department's Outreach Program. For more information about the LEx boxes program, visit its web page".

Name*
Given Family
Title*
Teacher, Principal, etc.
School or Intitution*
School or Institution Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Enter Email Confirm Email
Phone*
Alternative Phone
Principal's Name*
Given Family
Principal's Email*
Have you attended our teacher professional development workshop on circuit making, or the circuit workshop through Experience Science Day?*
- Yes
- No
Please note that we require the teachers to have taken our professional development workshop, or participated in the circuits activity during the Experience Science Day event. Teacher who do not fulfill this requirement, but are familiar with electrical components and comfortable with our kit content should contact outreach@phas.ubc.ca before submitting a request.
Which classes/ grades will you teach with this equipment?*
How many students in each class?*
Which LEx Box would you like to borrow?*
- Circuit Building
- Light Bulb Efficiency
- Energy
- Climate
Here is the list of materials for each box: Climate, Electronics, Energy, Light Bulbs
When would you like to borrow the LEx Box?*
MM slash DD slash YYYY

See availability on the following calendar
When will you bring the LEx box back to UBC?*
MM slash DD slash YYYY

Not more than four weeks
Any other notes or further details?
I have read the terms and conditions and agree to adhere to them*
I will return the LEx Box in good, orderly condition and by the due date. I understand that failure to comply with these terms may result in loss of borrowing privileges and/or replacement costs for any damaged or missing items, and that a late fee of $5 per day and delivery cost of $15 per trip will be assessed. If there is significant damage to the contents beyond the normal wear and tear of use in a supervised school setting, UBC Physics and Astronomy Outreach reserves the right to contact the principal in order to collect a refund for damaged material. I understand that UBC Physics and Astronomy Outreach, its directors, officers, employees, and other representatives are not responsible for personal injury, loss of life, or damage to property or both, resulting directly or indirectly from the use of the LEx Box equipment.
- I agree
Comments
This field is for validation purposes and should be left unchanged.

Resources

LEx Box Borrowing Form