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2. Today's Date *
   Today's Date
3. Teacher's First Name*
4. Teacher's Last Name*
6. School Name*
7. School District *
9. School Address*
11. City*
12. State*
13. Zip Code*
15. Teacher Phone Number*
16. Teacher Email Address*
18. Grade Level *
19. Number of Classes*
20. Total number of students, all classes*
22. Program Type*
    -- Select One --Museum Field Trip - $7 full-price per studentLanesfield Farm Family - $4 full-price per studentLanesfield Living History - $150 full-price per class

    Select the program you plan to attend.

23. Title One designation letter*
    Please upload a copy of the designation letter. School principals typically have this documentation.
25. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
27. Electronic Signature
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field