STEM City Robotics Kit Request Form
Thank you for your interest in borrowing one or more kits from us.  Our goal is to foster robotics education and knowledge across Flagstaff and Northern Arizona.

Given our limited supply (currently 12 kits), we will aim to distribute fairly across multiple populations (age, gender, socioeconomic status, culture) on a first come first serve basis.  The information we ask below is so that we get a good sense of your needs and also so that we can plan for future use of the kits.  Our goal is to eventually acquire more and so any information you share may be used for future grant and funding applications.

Additionally, in order to keep the kits in circulation, we'd like to have them returned in relatively good shape (or at least fully functional).  A few missing Lego pieces here and there are understandable, but the loss or non-return of hubs, sensors, and motors will trigger a donation request for us to be able to purchase replacement pieces.  Completion of this request and your virtual signature at the bottom of this form indicate your acceptance of these terms.

After you fill out this order request, we will contact you to go over details and availability before the order is completed. In the meantime, please direct any questions to us at coordinator@flagstaffstemcity.com.
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Last name *
First name *
Email address *
Phone number *
City *
Organization *
Population to be served *
Number of kits desired *
Start date *
MM
/
DD
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YYYY
Length of time desired (months) *
Would you like training/support to assist in your use of the kits? *
Would you like curriculum suggestions for use of your kits? *
Questions and comments
Certification *
By typing my full name below, I certify that I will adhere to the return/replacement terms listed at the top of this form.
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