Fairmount Waterworks Teacher Request Form

Fairmount Water Works Interpretive Center

Teacher Request Form

Note: please review our Educational Programs page prior to filling out the form below.

Please fill out all fields carefully. Fields with an asterisk (*) are required entries.

	CONTACT INFORMATION:
School name *
Teacher name *
Street Address
City
State
Zip Code
Teacher phone number (school) *
Alt Teacher contact phone number (cell)
Alt teacher contact phone no. (home)
Teacher contact email address (school) *
Alternate teacher email address (home)
Preferred date of visit*
Alternative date of visit*
	CLASS VISIT INFORMATION:
Number of students (up to 60) *
Grade level (s) of class *
Number of school chaperones * Note: 1 per 10 students is recommended
Preferred educational program for visit *
For more information on our programs, see the Educational Programs page.
	SPECIAL NEEDS:
Are any students hearing impaired?	Yes: No:
Are students physically disabled?	Yes: No:
Are any students learning disabled?	Yes: No:
Additional notes or questions:
	LUNCH:
	We do not have a designated lunch facility. Lunch can be held outside weather permitting.

Please provide any additional notes or special requests here.
	Contact Us: Emilie Hickerson (215) 685-0723 Fairmount Water Works Interpretive Center 640 Waterworks Drive Philadelphia, PA 19130