Service Learning Reservation Form

Service Learning Reservation Form
School Name, Organization, or Company*
Date of Event*

MonthDayYear
Date for your event
Desired Beginning and End Time*

AM/PM Option

Until
until

AM/PM Option
Contact Name*

First NameLast Name
Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone Number (if applicable)
Best number to reach you.
Contact Email Address*
Grade Level (if applicable)
Number of Students and/or Attendees*
Number of Teachers (if applicable)
Method of Transportation (Buses, Vans, Special Parking, etc.)*
If arriving by bus(es), please note if parking will be needed.
Objective of Visit*

Are you interesting in watching a movie?*

YesNo
What movie would you like to watch?*
Adaptive Needs or Sensory Notes*
Closed Captioning Cup Holder, Descriptive Narrative Headsets, Accessible Seating, Service Dogs welcome, etc.
Would you like to add pizza to this event (+$5pp)?*

YesNo
Will students/attendees purchase concessions?*

YesNo
Would you be interested in more information regarding a Prospector Gourmet Popcorn fundraiser?*

YesNo
Note: Outside food is strictly prohibited. Please inquire regarding guests with allergies.

Service Learning Agreement
Program 1 Total:
Program 2 Total:
Program 3 Total:
Program 4 Total:
Program 5 Total:
Program 6 Total:
Program 7 Total:
Program 8 Total:
Program 9 Total:
Program 10 Total:
Program 11 Total:
Program 12 Total:
Program 13 Total:
Pizza Total
Service Learning Estimate
Total Estimated Cost of Service Learning: $ {serviceLearning101} {pizzaTotal}
What is your preferred method of payment for this Service Learning?*

CheckCredit Card
Name of Signer*

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Service Learning Programs