Spring/Fall Program Request Form 2024

Program Request Form 2024
Email*
example@example.com
Name*

First NameLast Name
Daytime Phone Number*
Please enter a valid phone number.
What is your communication preference?*

EmailPhoneOther
Organization name:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What type of organization is your group?*
If other, what type of organization are you with?
What is your role?*
What grade level is this request for?*

Pre-KindergartenKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th GradeHigh SchoolCollegeOther
How many students/participants are you expecting to participate in this program?*
How many adults/chaperones are you expecting to be present for this program? (No more or less than 1 or 2 staff/adult chaperones per 10 students)*
Which program(s) are you interested in?*
What goals/ learning objectives do you have for the program?
Program Date and Time Selection

Please select the desired date on the calendar, and either 9:30-11:30am or 12:30-2:30pm for time slot
Program Date and Time: *

MonthDayYear
Date
Hour MinutesAM/PM Option
Select a time for your field trip*

9:30 - 11:30am12:30 - 2:30pm
Are you planning to have an independent, self-led group lunch on property before or after the program?*

YesNo
Would you like to take time during the scheduled program to have a snack break with your group?

YesNo
If you would like to include a snack break in the program schedule, what time and duration would you prefer?
How will payment be completed?*

A check will be mailed to Merck ForestPayment will be made day-of (Check preferred, but cash accepted)
Who should the invoice be emailed to?*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
Does your group have a certificate of insurance?*

YesNo
Please upload a copy of your group’s certificate of insurance. If your group does not have a certificate of insurance, a liability waiver (this will be emailed to you) must be filled out for each participant.

Cancelof
Is there anything else you would like to share with us for your program request?
Leave blank- for Education Team to fill out
Program Agenda/Schedule
Notes or comments
Group size charge ($75 for up to 15 students, $5 per student for each student over 15, up to 35 students)
School Contribution / Amount Due
Should be Empty:

Program Request Form 2024

Program Date and Time Selection

Leave blank- for Education Team to fill out