Field Trip Registration – Coweta STEM Institute

School Name

Teacher/Contact Person:

First

Last

E-mail:

Phone:

Area Code

Phone Number

Address:

Street Address City State / Province / Region Postal / Zip Code Country

Word Verification:

Title of Field Trip

Date Requested

Number of Classes:

Number of Students:

Number of Teachers (minimum of one per class):

Number of other adults (max of two per class):

Payment Options:

$6.00 per student (CCSS)

$7.00 per student (CCSS Planetarium)

$9.00 per student (non-CCSS)

$11.00 per student (non-CCSS Planetarium)