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Old State House Field Trip Registration

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* 1. Please enter your information below.

Name of School:

City, State:

Teacher/Group Leader:

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* 2. Please list your top three choices for a visit date:

1.

2.

3.

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* 3. Program Choice(s)

History Is All Around Us

My Community and Me

The Legend of the Charter Oak

Discover the Old State House

Connecticut's 3 Branches and How They Work

Prudence Crandall and the Black Law

Connecticut in the Civil War

Revolutionary Connecticut

Freedom Once Taken: The Amistad Story

The Place Where You Live (multi-site visit with the Wadsworth Atheneum)

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* 4. How many students will attend field trip?

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* 5. How many adults (teachers, paras, chaperones, etc.) will attend the trip?

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* 6. Grade/Age Level of Students

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* 7. What time will your group arrive?

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* 8. What time do you need to leave?

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* 9. Will your group eat lunch here? (Please note: there is no charge to eat outside on the lawn but there is a $25 lunch room fee to eat inside the building)

Yes

No

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* 10. If they are eating lunch here, what time would you like lunch to start/end?

Start Time:

End Time:

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* 11. How many buses/vehicles will you bring?

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* 12. Additional Information/Special Needs

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* 13. Teacher/Group Leader Email:

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* 14. Teacher/Group Leader Phone Number:

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* 15. What is the best way to reach you?

Email

Phone