BLISS Workshop Request

Employee Information
Last Name
First Name
Employee ID#
Division
Position Title
Email Address
Phone Number
Cell Phone
Fax

Reason for Attending Workshop (check all that apply)
	General interest in providing science outreach
	Want to assist specific student
	Want to assist specific teacher
	Want to assist specific school
	Recreational event i.e., birthday party
	Opportunity for professional development
	Other, Please explain


BLISS Kit Workshop

(510) 486-5511

Building 7, Room 220A
Supported by a generous gift from the S.D. Bechtel, Jr. Foundation