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.Format: (000) 000-0000.
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?
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)?
Will students/attendees purchase concessions?
Would you be interested in more information regarding a Prospector Gourmet Popcorn fundraiser?
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?
Name of Signer

First NameLast Name
Signature
Date

MonthDayYear
Date
Should be Empty:

Service Learning Programs