Enviromobile Registration Form

8695 Broadway, Merrillville, IN 46410
(219) 853-2420

Programs require 45-60 minutes.
A central location (science lab or community room) is best if available.
Multiple days may be required depending on number of classes being registered.
If you are interested in applying for our semester-long Worms in the Classroom traveling compost bin, please read and complete our WIC application

I am registering for a *

If other, please indicate what type of group

Contact Name *

Email Address *

School/Group Name *

Address *

City / State *

Grade/Age Level *

# of Classes/Groups *

Phone Number *

Cell Phone *

Please provide three (3) possible dates for your visit. Scheduling is on a first come, first serve basis.

(This registration is for school year only. For a summer program, please register through the Summer Enviromobile form).

1^st Date Choice *

2^nd Date Choice *

3^rd Date Choice *

Please select (√) your program choice *

If you are interested in applying for our semester long Worms in the Classroom Traveling Compost Bin, please apply using our WIC Application

To assist in scheduling, please list:

School Start Date

Spring Break Start Date

Earliest Start Time *

Dismissal Time *

Lunch Time

Specials' Time

Additional Information to assist scheduling