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October 16, 2020
Wednesdays at Madison
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Visit Request
Please select a date you are interested in from the list below.
Dec 4
Jan 29
Feb 5
Feb 12
Feb 19
Feb 26
Apr 16
Apr 23
Apr 30
School Information
High School Name
Hidden:
School CEEB Code
Mailing Address
Mailing Address
Country
Street
City
Region
Postal Code
School Phone
Do 50% or more of the students in your school participate in Free and Reduced Price Lunch?
Do 50% or more of the students in your school participate in Free and Reduced Price Lunch?
Yes
No
Will the bus pick-up location be different than the school mailing address?
Will the bus pick-up location be different than the school mailing address?
Yes
No
Bus Pick-Up Location
Bus Pick-Up Location
Country
Street
City
Region
Postal Code
Contact Information
I am a:
School Counselor
Teacher
Professor in Residence
First Name
Last Name
Hidden:
Email - setting device type
Email Address
Evening Phone
Mobile Phone
Primary Phone
Email Address
Hidden:
Email - copying to details tab
Hidden:
Email - copying to contact key
Hidden:
Phone - setting device type
Email Address
Evening Phone
Mobile Phone
Primary Phone
Phone
Hidden:
Phone - copying to details tab
Group Information
Primary Chaperone First Name
Primary Chaperone Last Name
Primary Chaperone Cell Phone
Number of Chaperones
We require one chaperone per 10 students with a minimum of two chaperones.
2
3
Number of Students
For transportation purposes the maximum group size including chaperones is 33.
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Grade Level of Students
Grade Level of Students
11th
12th
Will anyone in your group have any accessibility needs for this campus visit?
Will anyone in your group have any accessibility needs for this campus visit?
Yes
No
Please list any accessibility accommodations needed.
I understand that this form is only a request and that my group's visit is not confirmed until contacted by a staff member.
Submit
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