CCR Reservation Form

If this is your first time reserving a kit, please watch our orientation video before filling out this reservation form.
For questions, please call (812) 941-2277, or send an email to ccr@ius.edu.
Contact Information
Name First Last
Email
CCR ID #
Address 1
Street address Address line 2 City State/Province/Region Postal/Zip code Country
Home Phone - Area Code - Prefix Line Number
Work Phone - Area Code - Prefix Line Number
Fax - Area Code - Prefix Line Number
Kit Information
Kit Title/Code
Add a second Kit Yes
Kit Title/Code
Add a third Kit Yes
Kit Title/Code
Add a fourth Kit Yes
Kit Title/Code
Method of Kit Pick-Up
School for Pick Up (if not at IU Southeast)
Your School name
Grade Level
University Course (if applicable)
How many people will be impacted by the resources?
(Example: 30 students, 1000 festival attendees, etc.)
What are the expected ages of people experiencing the resources?
(Example: 1st grade, middle schoolers and parents, etc.)
Requested Dates
First Date Choice / MM / DD YYYY
Second Date Choice / MM / DD YYYY
Third Date Choice / MM / DD YYYY
For questions, please call (812) 941-2277, or send an email to ccr@ius.edu.
Quick Links
Checkboxes First option Second option Third option

Contact, Address and Additional Links