Program Request Form

School/Group Name*

Number of Children*

Age Range of Children*

Requested Program Date*

If you would like to book more than one date, please list them in the "additional questions/comments" section below.

Requested Start Time*

:

Program Grade*

Select all that apply.

Preschool Programs*

Check each one you are interested in.

School Aged Programs*

Check each one you are interested in.

Contact Person*

Address*

Telephone (day)*

Email*

Payment Source*

For example: BOCES, PTA, school business office, etc.

Additional Questions/Concerns