Barlow Planetarium & Weis Earth Science Museum
Field Trip Request Form

Teacher Information

Name: Phone:

Email: (required)

School Information

School name:

Address:

City: State: Zip:

Group Information

Lowest Grade Level:

Highest Grade Level:

Number of Students:
(Fees:  $4.00/student for single programs, $7/student for double programs, $10.50/student for triple programs)

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

Program Information

Program #1: (Minimum Fee:  $50)

Program #2: (Minimum Fee:  $50)

Program #3: (Minimum Fee:  $50)

Date/Time Request

1st Date Choice: Time:

2nd Date Choice: Time:

3rd Date Choice: Time:

Extras

Gift Shop?

Lunch Area? (Additional Fee: $30)