MakeHERspace Inc. STEM Equipment Request FormΔ MakeHERspace Inc.STEM Equipment Request FormThis form is used by schools, libraries, and community organizations to request STEM equipment support, lending kits, or program resources.1. Organization InformationTell us about your school or organizationOrganization NameType of Organization School Library Nonprofit Community Center OtherOther Organization TypeOrganization AddressAddress Line 1Address Line 2CityStateZIP CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)RomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweWebsite (if applicable)2. Primary Contact InformationWho should we contact regarding this request?First NameLast NameTitle/RoleEmailPhone NumberPreferred Contact Method Email Phone Text3. Request DetailsSome description about this sectionType of Request STEM Equipment Loan Classroom Kit Donation Workshop Support Materials Robotics/Tech Kits Coding & Electronics Kits OtherOther Request TypeEquipment RequestedNumber of Students/Participants ServedAge Group Elementary (K–5) Middle School (6–8) High School (9–12) College/Adult Mixed Ages4. Program or Usage InformationSome description about this sectionHow will the equipment be used?Duration of Use One-time event 1–2 weeks 1 month Semester Ongoing programRequested Start DateEnd Date (if applicable)5. STEM Focus AreaCheck all that applySTEM Focus Area Robotics Coding / Computer Science Engineering Science Experiments Mathematics Enrichment Environmental Science Makerspace / Hands-on Innovation OtherOther STEM Focus Area6. Equity & Impact InformationSome description about this sectionDo you serve underrepresented or underserved communities? Yes No PartiallyDescribe expected impact on students/participants7. Support & LogisticsSome description about this sectionDo you need training or setup support? Yes NoWill you be able to return equipment (if loaned)? Yes No Not Applicable (Donation Requested)Storage conditions available Secure classroom Storage closet Library8. Additional Notes or Special RequestsSome description about this sectionAdditional Notes9. AgreementBy submitting this form, the requesting organization agrees to use equipment responsibly and for educational purposes only, return loaned items in good condition (if applicable), and provide acknowledgment of MakeHERspace Inc. support when possible. I agree to the terms of the MakeHERspace Inc. STEM Equipment Request Agreement.Submission Information:Return completed forms to: MakeHERspace Inc. Equipment & Grants TeamEmail: support@makeherspace.org | Website: www.makeherspace.orgSubmit Form
