Survey - Education - Kind Kids Field Trip request form

Education - Kind Kids Field Trip request form

Teacher Information

Please provide the following information:

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Name:

First Required	Last Required

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Email: Required

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Phone Number: Required

Yes, I would like to receive e-mail from Humane Society Silicon Valley

Remember me. What's this?

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Question - Required - What grade level do you teach?

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Question - Required - Number of interested classes:

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Question - Required - Number of anticipated students per class:

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Question - Required - Number of anticipated adult chaperones:

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Question - Required - What specific dates or time frames (ie. Fall, Winter, or Spring 2012/2013) would like to visit HSSV for "Kind Kids?" Please list them here:

School Information

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Question - Required - Is this school Title I eligible?*

Question - Not Required - Will your school require assistance with the bus fee? (We will be in touch with you about this process)

NOTE: If this school is not Title I eligible, please contact Jamie Haupt to discuss scheduling a similar program at jhaupt@hssv.org or 408.262.2133 ext. 137

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Question - Required - School Name:

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Question - Required - School Address:

(Maximum response 255 chars, approx. 5 rows of text)

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Question - Required - Principal's first and last name:

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Question - Required - School phone number:

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Question - Required - In order to best meet the needs of your students, what category best describes your class? ESL/EFL
GATE
STUDENTS WITH SPECIAL NEEDS
OTHER:
NONE

Question - Not Required - If other, please describe:

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Question - Required - Does this field trip complement any themes you are currently working on with your class?

Question - Not Required - If yes, which themes?

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Question - Required - How did you hear about HSSV's Kind Kids Field Trip program?