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2019/20 Surgery Live! Reservation Form
Form Description
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* Indicates required question
Email
*
Your email
School Name
*
Your answer
School District/County
*
Your answer
EOF Eligible
*
Yes
No
Maybe
Teacher Name
*
Your answer
Email Address
*
Your answer
Day of trip contact phone number
*
Your answer
School Address
*
Your answer
School Phone Number
*
Your answer
Type of School
*
Public
Private
Charter
Daycare/Preschool
Other
Surgery Dates Available (1st Choice)
*
June 25- Hysterectomy
July 28- Gastric
Surgery Dates Available (2nd Choice)
*
June 25- Hysterectomy
July 28- Gastric
Arriving By
*
School Bus
Charter Bus
Van
Walk
Required
Departing By
*
School Bus
Charter Bus
Van
Walk
Required
Departure Time
*
Time
:
AM
PM
Any additional notes
Your answer
Student Tickets
*
Your answer
Adult Tickets (Please note, adults will need a paid ticket)
*
Your answer
Grade Level
*
Your answer
Special Needs?
Your answer
Lunch Options
*
Bring Lunch, would like space in Whitaker Center
Offsite Lunch
Not eating lunch during visit
Required
How did you hear about Surgery Live?
*
Field Trip Planner in the mail
A teacher at my school
A teacher at another school
We come every year!
Website
Other
Required
If a legislator was to stop by Whitaker Center, would your group be willing to do a meet and greet opportunity?
*
Yes
No
Please sign me up for Whitaker Center's email marketing list so I can be the first to learn about new educational programming, special events, documentaries, and more!
*
Yes, I would like to be included.
No, I would not like included at this time.
Are there any other teachers you know that would be interested in receiving information about Surgery Live! If so, please provide their name and contact information! Thank you!
Your answer
Send me a copy of my responses.
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