Classroom/Group Registration Form

Classroom/Group Registration Form

VIP Moments
VIP Moments celebrates youth who are at risk of dropping out or are current dropouts with classroom/group birthday party field trips given academic, behaviorial, and/or attendance improvement or re-entry. Visit our gallery for a unique experience that inspires and promotes school re-engagement/re-entry.

Register your classroom/group below and select your preferred schedule. If you have any questions, please call (860) 404-6072 or email vipmomentsbyus@gmail.com
Registrant Information
Name

First NameLast Name
Title

AdministratorParentTeacherOther
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School/Organization Name
Field Trip Details

Youth Gallery
Reservation Date
Number of Students
Please indicate the name, id, and grade level of the students below:
Number of Guests
Will there be guests? If yes, please identify them below:
What is your preferred cake flavor?

VanillaChocolate
What is your preferred ice cream flavor? (Up to 2)

ChocolateVanillaStrawberry
Select your preferred activity (Limit of 2)

Map of D.R.E.A.M.sMirror Mirror on the WallSelfie space
What do you expect your students will learn or gain in this field trip?
Do you have any comments, questions suggestions, or special instructions?
Do any participating parties have allergies (i.e., teachers, youth/students, chaperones)? Please list below.
How did you hear about this program?
Terms & Agreement
- All youth/students will conduct themselves with courtesy and respect toward all parties participating in the field trip, including but not limited to, youth/students, chaperones/teachers, and all personnel interacted with during the field trip.
- Students will respect public and personal property. Any damages incurred to property as a result of misconduct will be held responsible.
- Our accounting department will send you the payment information within 24-48 hours after completing this form. Please take note that we only work on business hours and business days.
- For cancellation, please send an email 10 days before the scheduled date. If the cancellation is made below 10 days, a cancellation fee will be charged. Cancellation made 3 days before the event will not be refunded.
- By completing this form, you understand that you are required to follow the rules and regulations of VIP Moments during the field trip.
Registrant Signature

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Date Signed

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Date
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Classroom/Group Registration Form

Registrant Information

Field Trip Details

Terms & Agreement