Group Registration

School/Group Information

School/Group Name: *

School/Group Address: *

Building, Floor, Room #:

City: *

State: *

Zip: *

Phone Number: *

Fax Number:

Teacher/Leader Contact Information

Name: *

Phone Number: *

Cell Phone:

Email: *

Best time of day to reach you?:

Trip Organizer's Contact Information

Name: *

Phone Number: *

Email: *

NYC Public School Information

Region Number:

Do you receive Title 1 funding?:

Yes

I don't know

Date(s) would you like to visit the Action Center

First Choice:

Second Choice:

Third Choice:

Which times do you prefer?:

10am - 12pm

1pm - 3pm

About Your Class/Group

Number of students:

(Thirty students is considered one class)

Number of chaperones:

(One chaperone per ten students required)

Grade of Students:

(Currently workshops in the Action Center are geared toward a middle school and high school audience. We will be adding elementary level workshops in the future)

Any Special Needs?:

Any Questions?:

CAPTCHA

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Math question: * 8 + 3 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.