School Program Request Form

General Information

School/Organization Name (required)

Street Address (required)

City, State & Zip Code (required)

School / Organization Phone # (required)

School/Organization Type (required)

Public SchoolPrivate/Parochial SchoolHomeschoolOther Youth GroupCollege/University

Which of the following best describes your group? (shift+click to select more than one)

General education/audienceInclusion (general education classes that include special education students)Special Education (classes of students with IEPs taught by special education teachers)Physical challenges (some participants have trouble with mobility)

Number of Students / Participants (required)

Grade Level or Age Range (required)

Number of Classes

Contact Information

Main Contact First Name (required)

Main Contact Last Name (required)

Main Contact Cell Phone # (required)

Main Contact Email (required)

Program Request

Select Program Type (select one)

VirtualAt MuseumAt your school/organization

Select a Program (select one)

Virtual School - Burning of Fairfield (grades 5-8)Virtual School - Creating Community (grades 3-5)In Person School Program

Please list below at least two choices for a program date. Please specify month and date:

First Date Choice (required)

Second Date Choice (required)

Third Date Choice

Estimated time of arrival. Please allow enough travel time to arrive 15 minutes before your program.

Estimated time of departure:

Are you requesting space for lunch?
YesNo

Additional information about your group that will help us to meet your needs and expectations:

Financial Assistance Request
The Fairfield Museum is committed to offering opportunities for schools in need through the generous support of funders and private donors. Program fees and funds for buses are available on a first come, first served basis. Schools must have at least 50% of its students receiving free/reduced lunch.
Do you request financial assistance for your school/organization group?
YesNo