Enviromobile Registration Form

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

Programs require 45-60 minutes.
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 Please select only ONE *

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 *

Last Day of School *

Fall Break Start Date *

Fall Break End Date *

Winter Break Start Date *

Winter Break End Date *

Spring Break Start Date *

Spring Break End Date *

Earliest Start Time *

Dismissal Time *

Lunch Start Time *

Lunch End Time *

Specials Start Time *

Specials End Time *

Additional Information to assist scheduling