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LEx Box Form
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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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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.
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