Illinois Holocaust Museum & Education Center

09-10 Request Form

PLEASE NOTE: We are in the process of revising our tour options and will begin accepting reservations for the 2010-2011 school year on July 1, 2010.

2009-2010 REGISTRATION PROCESS

A completed registration form must be received by our Education Department in order to process and confirm your request. You will receive confirmation of your registration within 2-3 weeks.

PLEASE NOTE: Your field trip date is not confirmed until you receive a confirmation letter.

Request forms are processed in the order in which they are received and according to availability. We will try our best to fill your request but cannot make any guarantees. Please provide us with at least three weeks’ notice in advance of your requested date.

If you wish to request multiple visit dates and times, please fill out one request form for each proposed visit.

School Information

School Name

School Address

City

State

Zip

Main Phone

ex. 123-456-7890

Grade Level of School

Contact Information

First Name

Last Name

Job Title/Role Within School

(optional)

Work Phone

ex. 123-456-7890

Home Phone

(optional)

Cell Phone

(optional)

Visitor Information

What type of transportation will you be using?

Bus

Private vehicles or vans

Grade Level of Class

Subject Taught

(optional)

Type of School

Please note that we require payment for all registered visitors and do not offer refunds for absentees or reduced numbers once your request is confirmed.

Number of Students

(refer to field trip options below)

Number of Chaperones

Number of Medically Necessary Aides

Note: We require 1 chaperone (18 or older) for every 10 students. No exceptions can be made.

Special Needs
(optional)

Time & Date of Visit

Note: It is not always possible to accommodate your first choice. Request forms are processed in the order they are received and according to availability.

More Information - Tour Options (opens in new window)

Please choose from the following field trip options. You may check more than one to indicate flexible availability. Times listed are firm and cannot be changed.

1st Choice Date & Time

Date

Trip	Option	Grade Level	Time	Max Students	Docent-Led
	A1	7-12	9:00am - 11:45am	120
	A2	7-12	9:00am - 12:10pm	120
	A3	7-12	11:00am - 2:20pm	120
	A4	7-12	11:25am - 2:20pm	120
	A5	7-12	1:00pm - 3:00pm	200	Self-guided
	B	6	10:45am - 2:00pm	80
	C1	3-5	10:15am - 12:00pm	40
	C2	3-5	10:15am - 12:30pm	40

THURSDAY EVENINGS
	E1	7-12	5:00pm - 7:45pm	120
	E2	6	5:00pm - 7:30pm	80
	E3	3-5	5:00pm - 6:45pm	40

WEEKEND TRIPS
	D1	7-12	11:00am - 1:45pm	120
	D2	7-12	11:00am - 2:10pm	120
	D3	6	12:45pm - 4:00pm	80
	D4	3-5	12:15pm - 2:00pm	40
	D5	3-5	12:15pm - 2:30pm	40

2nd Choice Date & Time

Date

Trip	Option	Grade Level	Time	Max Students	Docent-Led
	A1	7-12	9:00am - 11:45am	120
	A2	7-12	9:00am - 12:10pm	120
	A3	7-12	11:00am - 2:20pm	120
	A4	7-12	11:25am - 2:20pm	120
	A5	7-12	1:00pm - 3:00pm	200	Self-guided
	B	6	10:45am - 2:00pm	80
	C1	3-5	10:15am - 12:00pm	40
	C2	3-5	10:15am - 12:30pm	40

THURSDAY EVENINGS
	E1	7-12	5:00pm - 7:45pm	120
	E2	6	5:00pm - 7:30pm	80
	E3	3-5	5:00pm - 6:45pm	40

WEEKEND TRIPS
	D1	7-12	11:00am - 1:45pm	120
	D2	7-12	11:00am - 2:10pm	120
	D3	6	12:45pm - 4:00pm	80
	D4	3-5	12:15pm - 2:00pm	40
	D5	3-5	12:15pm - 2:30pm	40

3rd Choice Date & Time

Date

Trip	Option	Grade Level	Time	Max Students	Docent-Led
	A1	7-12	9:00am - 11:45am	120
	A2	7-12	9:00am - 12:10pm	120
	A3	7-12	11:00am - 2:20pm	120
	A4	7-12	11:25am - 2:20pm	120
	A5	7-12	1:00pm - 3:00pm	200	Self-guided
	B	6	10:45am - 2:00pm	80
	C1	3-5	10:15am - 12:00pm	40
	C2	3-5	10:15am - 12:30pm	40

THURSDAY EVENINGS
	E1	7-12	5:00pm - 7:45pm	120
	E2	6	5:00pm - 7:30pm	80
	E3	3-5	5:00pm - 6:45pm	40

WEEKEND TRIPS
	D1	7-12	11:00am - 1:45pm	120
	D2	7-12	11:00am - 2:10pm	120
	D3	6	12:45pm - 4:00pm	80
	D4	3-5	12:15pm - 2:00pm	40
	D5	3-5	12:15pm - 2:30pm	40

If you have a strong preference for one field trip option over another, please indicate that option here:

Preference

(optional)

Payment Method

IHMEC requires a $50 deposit to hold your scheduled field trip. This deposit will be applied toward the cost of your trip. We will hold your tour spot for 15 business days after sending your confirmation letter. If payment is not received within that time frame, the tour spot will be released for other school groups.

How do you plan to pay your deposit?

Credit Card

Check

IHMEC Information

To save trees and postage, IHMEC prefers to email your confirmation letter and pre-visit information.

Yes, please email me all necessary information. I am able to download.

No, please mail me a hard copy of my confirmation letter and pre-visit information.

How did you hear about IHMEC Field Trip Tour Program?

Teacher training workshop

Summer Institutes

Field trips brochure

Website

Colleague

Other

I have read and agree to the terms and conditions outlined in IHMEC's Field Trips policy. I will follow all procedures outlined in the Pre-Visit Packet and Chaperone's Guide.