Organization's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Daytime Phone *

(###)

###

####

Please list your desired date of program visit in order of preference: *

MM

DD

YYYY

*

MM

DD

YYYY

*

MM

DD

YYYY

Please list your desired time for the program visit. Please note that sessions take approximately 50 minutes. *

Hour

Minute

Second

AM PM

Hour

Minute

Second

AM PM

Hour

Minute

Second

AM PM

I, _____________________________ as the lead teacher/contact person for the above organization have read and understand the Neighborhood Fossils guidelines prior to submitting this request. I understand that WSC staff will facilitate the activities but help from teachers or staff is needed to keep the small group structure of the activities and it is my responsibility to plan and distribute this information to all teachers/staff attending the labs. I understand that payment is required two weeks prior to the program date(s) and that WSC does not provide refunds. *

Yes, I understand the above terms and conditions.