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2021-22 Surgery Live! Reservation Form
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* Indicates required question
Email
*
Your email
School Name
*
Your answer
School District
*
Your answer
County
*
Your answer
STEM Scholarship Eligible
*
Yes
No
Maybe
Teacher's Name
*
Your answer
Teacher's Email Address
*
Your answer
Day of trip contact phone number
*
Your answer
School Address
*
Your answer
School City, State, Zip code
*
Your answer
School Phone Number
*
Your answer
Type of School
*
Public
Private
Charter
Other
Surgery Dates Available (1st Choice)
*
March 23, 2022
March 24, 2022
April 5, 2022
April 12, 2022
July 12, 2022
July 13, 2022
August 11, 2022
Surgery Dates Available (2nd Choice)
*
March 23, 2022
March 24, 2022
April 5, 2022
April 12, 2022
July 12, 2022
July 13, 2022
August 11, 2022
Surgery Dates Available (3rd Choice)
*
March 23, 2022
March 24, 2022
April 5, 2022
April 12, 2022
July 12, 2022
July 13, 2022
August 11, 2022
We would like to view Surgery Live!
*
In person at Whitaker Center
Virtually, in our classroom at school
If coming to Whitaker Center, you will arrive by
School Bus
Charter Bus
Van
Walk
Clear selection
If coming to Whitaker Center, you will depart by
School Bus
Charter Bus
Van
Walk
Clear selection
If coming to Whitaker Center, where will you have lunch?
Bring lunch, you like space at Whitaker Center
Offsite Lunch
Not eating lunch during visit
Clear selection
Departure Time
Time
:
AM
PM
Any special needs?
*
Your answer
Student tickets
*
Your answer
Adult tickets (Please note, adults will need a paid ticket)
*
Your answer
Grade Level
*
Your answer
Would you like to include the Surgery Live! Extension Experience program in your itinerary? Please note, this option is only available for those viewing Surgery Live! at Whitaker Center.
*
Yes
No
Any additional notes:
*
Your answer
Submit
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