Teacher Information

Your name: ______________________________

Work Phone:_____________________________

Home Phone:_____________________________

Fax:____________________________________

Email:___________________________________

School Information Name:_________________________________

Address:_______________________________ ______________________________________ ______________________________________

Grade ___________

Number of Students: ___________

Number of Chaperones: ___________

(1 chaperone to 6 students for grades K-6)

(1 chaperone to 8 students for junior high)

(1 chaperone to 12 students for high school)

Program: (Select One)

Ramada Talk: _______ (10 - 15 minutes)

Lower Cliff Dwelling Talk ______(20 minutes)

(not including hiking time)

Other: _______________________________

(please specify)

Program Date/Time

1^st Choice: ________________ __________

2^nd Choice: ________________ __________

3^rd Choice: ________________ __________