Mobile Museum Registration For School & Community Programs Outreach School & Community Program Registration Form Outreach School & Community Program Registration Form Please fill out the following form in order to register for our outreach school & community group programming. Organization Name * Organization Address * Organization Address Organization Address Organization Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Address for Program Location (if different from Organization Address) Address for Program Location (if different from Organization Address) Address for Program Location (if different from Organization Address) Address for Program Location (if different from Organization Address) City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Contact Name * Contact Name First First Last Last Contact’s Phone Number * Contact’s Email * Program Selection * Dinos, Dinos, Dinos (PreK-5th grade) Amazing Animal Adaptations (PreK-K) Buggin’ Out (PreK-K) Looking Out My Backdoor (PreK) Exploring Earth (K) Earth and Sky (1st-2nd grade) How It’s Made (1st-2nd grade) Trait-astic! (1st-3rd grade) Animal Adaptations (3-4th grade) Most Extreme Animals (5-6th grade) Longwood Community Read: ‘Bring Me An Apple’ (Pre-K-2nd) How many Students/Participants will you have? (25 maximum per program) * How many Teachers/Adults will you have? * Age Range/Grade of Participants * Phone Number for Day of Contact (if different from Contact Phone Number) Parking Instructions * First Choice Date of Program (Monday-Friday) * Second Choice Date of Program (Monday-Friday) * First Choice Start Time of Program (8:30 a.m.-4:30 p.m.) * 121234567891011 : 0030 AMPM Second Choice Start Time of Program (8:30 a.m.-4:30 p.m.) * 121234567891011 : 0030 AMPM What are your organization’s policies on masks/social distancing in regards to Covid-19? Do your students/participants have any accessibility needs that we should be aware of? (non-English speaking, non-verbal, mobility needs, special needs, etc.) * Any additional concerns or questions? Please let us know here How did you hear about us? Title 1 or Free & Reduced lunch * select an option I work at a Title 1 School and/or we offer free/reduced lunch I work for an organization that serves students who receive funding None of the above applies to my school/organization If you are human, leave this field blank. Submit
