Education Program Request

Group Name *

School Name *

Name of Contact Person *

Title / Position

(Teacher, Administrator, PTO, etc)

Street Address *

Street Address 2

City / Town *

State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code *

Country * - Select -United StatesUnited KingdomCanadaAndorraUnited Arab EmiratesAfghanistanAntigua and BarbudaAnguillaAlbaniaArmeniaNetherlands AntillesAngolaAntarcticaArgentinaAmerican SamoaAustriaAustraliaArubaAzerbaijanBosnia and HerzegovinaBarbadosBangladeshBelgiumBurkina FasoBulgariaBahrainBurundiBeninBermudaBrunei DarussalamBoliviaBrazilBahamasBhutanBouvet IslandBotswanaBelarusBelizeCocos (Keeling) IslandsCentral African RepublicCongoSwitzerlandCote D\Ivoire (Ivory Coast)Cook IslandsChileCameroonChinaColombiaCosta RicaCzechoslovakia (former)CubaCape VerdeChristmas IslandCyprusCzech RepublicGermanyDjiboutiDenmarkDominicaDominican RepublicAlgeriaEcuadorEstoniaEgyptWestern SaharaEritreaSpainEthiopiaFinlandFijiFalkland Islands (Malvinas)MicronesiaFaroe IslandsFranceFrance MetropolitanGabonGreat Britain (UK)GrenadaGeorgiaFrench GuianaGhanaGibraltarGreenlandGambiaGuineaGuadeloupeEquatorial GuineaGreeceS. Georgia and S. Sandwich Isls.GuatemalaGuamGuinea-BissauGuyanaHong KongHeard and McDonald IslandsHondurasCroatia (Hrvatska)HaitiHungaryIndonesiaIrelandIsraelIndiaBritish Indian Ocean TerritoryIraqIranIcelandItalyJamaicaJordanJapanKenyaKyrgyzstanCambodiaKiribatiComorosSaint Kitts and NevisKorea (North)Korea (South)KuwaitCayman IslandsKazakhstanLaosLebanonSaint LuciaLiechtensteinSri LankaLiberiaLesothoLithuaniaLuxembourgLatviaLibyaMoroccoMonacoMoldovaMadagascarMarshall IslandsMacedoniaMaliMyanmarMongoliaMacauNorthern Mariana IslandsMartiniqueMauritaniaMontserratMaltaMauritiusMaldivesMalawiMexicoMalaysiaMozambiqueNamibiaNew CaledoniaNigerNorfolk IslandNigeriaNicaraguaNetherlandsNorwayNepalNauruNeutral ZoneNiueNew Zealand (Aotearoa)OmanPanamaPeruFrench PolynesiaPapua New GuineaPhilippinesPakistanPolandSt. Pierre and MiquelonPitcairnPuerto RicoPortugalPalauParaguayQatarReunionRomaniaRussian FederationRwandaSaudi ArabiaSolomon IslandsSeychellesSudanSwedenSingaporeSt. HelenaSloveniaSvalbard and Jan Mayen IslandsSlovak RepublicSierra LeoneSan MarinoSenegalSomaliaSurinameSao Tome and PrincipeUSSR (former)El SalvadorSyriaSwazilandTurks and Caicos IslandsChadFrench Southern TerritoriesTogoThailandTajikistanTokelauTurkmenistanTunisiaTongaEast TimorTurkeyTrinidad and TobagoTuvaluTaiwanTanzaniaUkraineUgandaUS Minor Outlying IslandsUruguayUzbekistanVatican City State (Holy See)Saint Vincent and the GrenadinesVenezuelaVirgin Islands (British)Virgin Islands (U.S.)Viet NamVanuatuWallis and Futuna IslandsSamoaYemenMayotteYugoslaviaSouth AfricaZambiaZaireZimbabwe

E-Mail Address *

Daytime Phone *

(Monday - Friday)

Ext.

Date of Requested Program *

Year Year20172018201920202021

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day Day12345678910111213141516171819202122232425262728293031

(Note: please enter the date you would like the program, not today's date)

Alternative Date *

Year Year2019202020212022

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day Day12345678910111213141516171819202122232425262728293031

In the event that your selected date is unavailable, please choose an alternative date.

Program Requested * - Select -Colonial Classroom VisitsWampanoag Classroom VisitsColonial Traveling WorkshopColonial Hands-on WorkshopWampanoag Hands-on WorkshopColonial OvernightWampanoag OvernightColonial Winter WorkshopScout Meeting

Second Choice - None -Colonial Classroom VisitsWampanoag Classroom VisitsColonial Traveling WorkshopColonial Hands-on WorkshopWampanoag Hands-on WorkshopColonial OvernightWampanoag OvernightColonial Winter WorkshopScout Meeting

Third Choice - None -Colonial Classroom VisitsWampanoag Classroom VisitsColonial Traveling WorkshopColonial Hands-on WorkshopWampanoag Hands-on WorkshopColonial OvernightWampanoag OvernightColonial Winter WorkshopScout Meeting

Number of Adults *

Number of Children / Students *

Age / Grade of Participants *

Have you ever participated in one of our programs before?

Yes

No

Last date you participated in one of our programs

mm/yyyy

Comments / Special Needs

Would you like to be added to our Education mailing list? *

Yes

No