Shenandoah GYSTC Electronic Science Field Trip Request Form

School Name 

Payment options:

$5.00 per student (GYSTC members all non planetarium field trips)

$6.00 per student (GYSTC members all planetarium field trips)

$8.00 per student (GYSTC members all non planetarium field trips)

$10.00 per student (GYSTC members all planetarium field trips)

Mailing Address

City State Zip Code County

E-Mail Address

Telephone FAX number

Teacher/Contact Person

Grade Level Number of Classes Number of Students

Title of Field Trip

Date Preferred, IF available: 

Number of Teachers(minimum of one per class)   Number of Other Adults (maximum of two per class)

Do you have any students with special needs? If so, please explain: