Outreach Visit Request Form
The Science Museum is here to serve you, and we do our best to schedule the topics you request. Outreach Programs are scheduled on a first-come, first-served basis. Please note that completing this form does not ensure your request is entered on our calendar. We will notify you by email or in writing when your request is confirmed.

One form per grade level, please.

Regarding any questions or concerns, please contact the Science Museum's Scheduler at 540-342- 5721 or email scheduler@smwv.org. We will respond to your inquiries as soon as possible.

Teacher/Group Leader's Name *
Your answer
Grade Level or Age Group *
Your answer
School/Group Name *
Your answer
School System
Your answer
Mailing Address *
Your answer
City *
Your answer
State *
Your answer
ZIP/Post Code *
Your answer
Phone (work)
Your answer
Phone (cell)
Your answer
Email
Your answer
Please contact me by: *
If by phone, what is the best time of day to reach you?
Your answer
Number of programs requested *
Your answer
Number of presentations of each program requested per day (5 maximum) *
Your answer
Number of students per presentation. Maximum: PreK (18); Kindergarten (24); others (30) *
Your answer
Program Choice #1. List program titles in priority order. We make every effort to schedule your top choices. For program descriptions, please refer to our website. *
Click down arrow for list of programs
Preferred Month of Visit (Program Choice #1) *
Your answer
Program Choice #2 *
Click down arrow for list of programs
Preferred Month of Visit (Program Choice #2) *
Your answer
Program Choice #3 *
Click down arrow for list of programs
Preferred Month of Visit (Program Choice #3) *
Your answer
Program Choice #4
Click down arrow for list of programs
Preferred Month of Visit (Program Choice #4)
Your answer
Program Choice #5
Click down arrow for list of programs
Preferred Month of Visit (Program Choice #5)
Your answer
Program Choice #6
Click down arrow for list of programs
Preferred Month of Visit (Program Choice #6)
Your answer
Day(s) Preferred *
Required
Daily class schedule begins and ends at what times? *
Your answer
Grade level lunch begins and ends at what times? *
Your answer
Is the time of lunch flexible? *
Are there any other times during the class day that might conflict with your schedule?
Your answer
Any special needs:
Your answer
I have read the presentation requirements for each outreach requested (remaining in one room, access to a water source, etc.) and our school can comply with the Museum Educator's needs. *
Required
I have difficulty meeting the following requirement in my classroom:
Your answer
Submit
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