School Group Virtual Program Request Form

Submitting this form is only a request—not a reservation. We will contact you to confirm your time slot and provide payment instructions. After we receive your payment we will send you a program confirmation email and will be in touch to set up the video conference. Please check your spam/junk folder for correspondence with the Museum Education Staff and review the confirmation materials.

Name of School/Organization *

Primary Contact *

First Name Last Name

Email *

example@example.com

Role in the organization *

Ex: teacher, administrator

Subjects/grades?

What subjects and grades do you teach?

Phone Number *

Area Code Phone Number

School/Organization Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

School/Organization Type *

Philadelphia Public/ Charter School Home School Private School Community Organization Suburban Public/Charter School Early Childhood Education Out of State Public / Charter School Afterschool Program

Students' Grades *

Curriculum Goals & Additional Information

Number of Students expected to participate in the activity at one scheduled time slot *

1-15 16-35 35 plus

Tell Us About Your Students

Please provide any information that maybe helpful to conduct the virtual experience, including but not limited to special needs.

School Group Virtual Program Request Form

Reservation Confirmation

Payment

PLEASE NOTE: