– Extended Learning – Elementary Inquiry Form

What you need:

A classroom or open space
3 large tables or desks
Access to a sink
School or Organization Representative to remain onsite

ORGANIZATION INFORMATION

School / Organization Name*

Type of Organization*

Name of facility where program will take place

Address*

Street Address City State / Province / Region ZIP / Postal Code

Contact Name*

Affiliation with the School / Organization

i.e. teacher, principal ...

Phone*

Email Address*

DAY OF EVENT CONTACT INFORMATION

Onsite Coordinator

Cell Phone Number

Cell phone is in case we need to reach you while enroute

Email Address

Best time to reach you?*

PROGRAM INFORMATION

Number of Students

20 students per class max

Grade Level / Age of Students

After School Science

Please select the topics that you are interested in:*

Why did you choose this program?*

Alignment with curriculum
Just for fun
Referred

Are you new to us?*

Yes
No

What you will need:

A classroom or open space
3 large tables or desks
Easy access to a sink
Representative to remain on-site

SCHEDULE

Start Date

End Date

Occurence

Weekly
Bi-Weekly

Day(s) of the Week

Tuesday
Wednesday
Thursday
Friday

Include "Early Release Days" or "Holiday Weeks"

Yes
No

Student Release Time

Anticipated Program Start Time

Session Time-frame

1-Hour Session
2-Hour Session

PAYMENT INFORMATION

How Program Will Be Funded?

School District
PTA
Title 1
Other

If other, please explain

How did you hear about us?

To be provided prior to the program start date

Student Check-In & Check-Out Policy
Class List with Emergency/Allergy Information
Disciplinary Policy
If Needed, Key Check-In & Check-Out Policy

** In order to reserve your program a non-refundable deposit will be required.

IMAGINE CHILDREN'S MUSEUM MUSEUM-ON-THE-GO CONTRACT

To ensure a successful visit, please review and check each item below. Your online submission of this form constitutes your agreement to each of the following terms. If you have any questions, please email reservations@imaginecm.org, or call 425/258-1006, Ext. 1012 on weekdays from 9:00 a.m. - 5:00 p.m.

A 50% non-refundable deposit is required at scheduling; remaining balance is due day of services. * If using a Purchase Order the deposit is not required, but if the program is canceled or a "no show" you will be charged the deposit amount.
Credit card information or Purchase Orders will need to be called in or faxed to the Museum by the date on the confirmation that you will receive.

Please note: The Museum no longer accepts personal checks.

Comments (special needs, etc.)

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