Reserve a program

Please fill out this form to begin the process of reserving a program and providing your students with a great science experience.
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.