Programs for Schools > Registration Request Form

Registration Request Form

Please provide the following information to make a Programs for Schools request.
Note: Use the tab key to move to the next item. Required items are indicated with an asterisk *.

Requested by:

School Name * :
School Phone Number * :	( ) -
Fax Number:	( ) -
Your Name * :
Home Phone Number: (if you are willing to be called at home)	( ) -
Best times to call: (Office hours are: Monday-Friday 8:30-4:30) between and at home or school between and at home or school between and at home or school between
Email Address *:

Program Requested:

Type of program you would like to request * :
Grade Level * :
Number of Students Attending * :

1st Choice

Title of Program * :

Mon. Tues. Wed. Thurs. Fri.

Preferred Dates *:
or

Preferred Time of Day for:

Programs Held at LHS:
Programs Held at Your School:
Multi-Session Programs:

2nd Choice

Title of Program:

Mon. Tues. Wed. Thurs. Fri.

Preferred Dates:
or

Preferred Time of Day for:

Programs Held at LHS:
Programs Held at Your School:
Multi-Session Programs:

3rd Choice

Title of Program:

Mon. Tues. Wed. Thurs. Fri.

Preferred Dates:
or

Preferred Time of Day for:

Programs Held at LHS:
Programs Held at Your School:
Multi-Session Programs:

School Address

School Address * :

City * :
State * :
Zip * :
Contact Person's Name * :
Teacher in charge of group on date of visit * :

Comments or Feedback:

Thank you for your inquiry. The Lawrence Hall of Science Registration Office will contact you shortly to confirm program availability, details, dates, and contract and payment requirements.

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