Please complete the application below

The Museum of Medical History is open Tuesday-Friday from 10am-4pm. Thanks to a generous donation from the SSVMS Alliance, schools can apply for transportation reimbursement for field trips to the Museum. Transportation must be reimbursed to the school/district, and cannot be reimbursed to individuals. Funding is limited and not all requests can be fulfilled. There is a $200 limit for transportation funding. For more information, contact Sam Mello at SMello@ssvms.org or 916-452-2671. 

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* 1. School name

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* 2. School address

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* 3. School district

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* 4. Teacher/contact person name

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* 5. Teacher/contact person phone number

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* 6. Teacher/contact person email

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* 7. Class/grade level

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* 8. Number of students

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* 9. Number of chaperones 

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* 10. Tour date/time requested

Date
Time

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* 11. Total transportation cost

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* 12. Total financial assistance requested

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* 13. Make check payable to

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* 14. Comments

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