Out of State School Reservation 2012-2013

Name of Group Leader *

Group Leaders Email *

Email address may be used for Adler updates and our teacher newsletter.

Official School Name *

Principal Name *

First Choice Date (MM/DD/YYYY) *

Last day for School Field Trips is Friday, May 31, 2013.

Second Choice Date (MM/DD/YYYY *

Last day for School Field Trips is Friday, May 31, 2013.

Third Choice Date (MM/DD/YYYY) *

Last day for School Field Trips is Friday, May 31, 2013.

Time of Arrival *

Time of Departure *

School Type *

Grade Level of Students *

Preschool Pre-Kinderarten Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade

Number of Students *

$6 per student

Number of Adult Teacher/Chaperones (Free with a minimum ratio of 1 adult to every 7 students) *

Please Indicate if you have students with special needs.

Do you wish to buy a lunch? A link to the lunch reservation form will be sent with your confirmation. *

No. Yes.

Do you wish to bring your own lunch and reserve seats in the lunchroom? (Lunch Room Capacity 128 People) *

No. Yes.

First Choice Lunch Time. (20 minutes allowed for lunch in lunchroom.) *

Second Choice Lunch Time. (20 minutes allowed for lunch in lunchroom.) *

Adler Planetarium