Field Trip Registration Form 
Please complete the following form to reserve a date for a visit to the Surratt House Museum (SHM). You may expect a response from a member of the SHM staff within 5 business days.
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Organization Information
School Full Name
 *
School Address
 *
Street Address, City, State Zip Code
School Office Phone Number
 *
School Type
 *
Required
Coordinator Information
Full Name
 *
Cell Phone Number
 *
Primary Email Address
 *
Confirm Primary Email Address
 *
Secondary Email Address
Group Information
We can accommodate a maximum of 40 students per visit. Please note that for grades K–5, SHM requires at least 1 adult / 5 students; and for grades 6–12, SHM requires at least 1 adult / 10 students. All chaperones must stay on-site for the full duration of the visit. No exceptions. For all chaperones within this ratio, their admission fees will be waived.
Grade level(s) and age(s)
 *
Number of Chaperones
 *
Number of Students
 *
Accommodations 
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Required
Additional Comments / Reasonable Accommodations
Preferred Visit Information
Preferred Visit Date
 *
MM
/
DD
/
YYYY
Time
:
Alternative Visit Date (if first choice is unavailable)
 *
MM
/
DD
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YYYY
Time
:
Alternative Visit Date (if second choice is unavailable)
 *
MM
/
DD
/
YYYY
Time
:
Additional Information
Please note that there is a $2 admission fee for every student, and a $5 admission fee for every chaperone in addition to the ratio described above. Please also note that SHM reserves the right to ask any group to leave if a member of their party violates appropriate standards of classroom behavior or explicit instructions provided by SHM staff. 
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