Barlow/Weis Field Trip Request Form

Name: Phone:

Email: (required)

School name:

Address:

City: State: Zip:

Lowest Grade Level:

Highest Grade Level:

Number of Students:
(Fees: $3.50/student for single programs, $6/student for double programs, $9/student for triple programs)

Number of Chaperones: (One adult chaperone is admitted free for every 10 students)

Program #1: (Minimum Fee: $50)

Program #2: (Minimum Fee: $50)

Program #3: (Minimum Fee: $50)

1st Date Choice: Time:

2nd Date Choice: Time:

3rd Date Choice: Time:

Gift Shop? Yes No

Lunch Area? Yes No (Additional Fee: $30)