Reservation Request Form

School Group Visit 2017 - 2018 Reservation Request Form Submit this form via email to [email protected], or fax to 718-604-7442. A reservationist will reply with a confirmation within 7 business days. Additional rescheduling will incur a charge of $10 per request.

INSTITUTION AND CONTACT INFORMATION School Name: Contact Name: ______Address: ______Contact Cell Number: ______City & Zip Code: ______Contact Email Address: ______Phone Number: ______School District Number: Title 1 School: □ Yes □ No

RESERVATION INFORMATION PREFERRED DATE OF VISIT: Reservations must be made at least one month prior to your visit. 1st choice ___/___/_____ 2nd choice ___/___/_____ 3rd choice ___/___/_____ □ Multiple Visits over Several Dates

Select from a wide range of inquiry-based Free Tuesday - Thursday □ Target Program natural and physical sciences, animals and, Target Programs for Title 1 schools: □ 10:15 am – 11:00 world culture programs led by educators. 2nd – 8th grades am □ 11:15 am – 12:00 . pm

$250 Tuesday - Friday □ Guided After your inquiry-based guided program, General Education Class up to 25 students □ 10:15 am – 11:00 Program continue your visit and explore the $175 am + Self-Guided Museum’s exhibits. Special Needs Class up to 12 students □ 11:15 am – 12:00 Exploration pm

□ Self-Guided Journey through BCM’s galleries and Tuesday - Friday Exploration explore the diversity of our collections. $8 per student □ 10:00 am – 1:00 pm

CLASS INFORMATION: Maximum size is 25 students for general education groups, and 12 students for special needs groups. BCM requires a ratio of 5 students to 1 adult, with complimentary admission to those adults. Groups will be charged $8 for every missing or additional chaperone and student. All paraprofessionals will receive complimentary admission with their special needs classes.

Teacher’s Name Teacher’s Email Guided Program Name or Grade Special # # Self-Guided Exploration Level Needs Students Chaperones □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No P a g e 1 | 3 □ Yes □ No LUNCH ACCOMMODATIONS: $5 per 15 students. All groups requesting lunch accommodations must select a reservation time in order to eat in the Café or Mezzanine. Groups that do not have a reserved lunch time are welcome to eat outdoors in nearby Brower Park. If there is inclement weather, BCM cannot guarantee space for groups without reservations. Do you need to reserve space to eat lunch? □ Yes □ No Will your group be purchasing lunch from our café? □ Yes □ No Preferred Lunch Time: □ 10:20am – 10:50am □ 11:00am – 11:30am □ 11:45am – 12:15pm □ 12:30pm – 1:00pm

PAYMENT INFORMATION: A 50% non-refundable fee or the full program cost is due when making your reservation. The program balance can be paid in cash, check (payable to Brooklyn Children’s Museum), credit card, or NYC Department of Education purchase order (PO # must be present at check-in). Cancellations require 48 hours’ notice and deposits are non-refundable.

Pay via Credit Card: Name on credit card Card Type Credit card # Expiration Date / / Security Code

Billing Street Address: ______Financial Contact Name: ______Billing City: ______Financial Contact Phone Number: ______Billing State: ______Billing ZIP: ______Financial Contact Email Address: ______

ACCESS PROGRAM QUESTIONNAIRE: For Groups with Special Needs We are committed to delivering programs that help all young people enhance and celebrate their abilities. We would like to know more about your class to make your program engaging and exciting for your students. My class is best described as: What are your goals for your students’ museum experience? o An inclusive class with some individuals with disabilities (Utilize the space below for additional goals) o A class made up of individuals with physical disabilities o Build on or introduce a curricular theme o A class made up of individuals with learning disabilities o Engage in hands-on learning o A class made up of individuals with both learning and o Participate in interpersonal interactions physical disabilities o Take part in an educational experience outside the classroom o Other: ______

Which interactive learning styles work best for your Describe your classroom communication techniques. students? o Students use non-verbal communication o Visual: pictures, charts, graphs o Students use verbal communication o Tactile: hands-on learning, making things, drawing o Students use both non-verbal and verbal communication o Kinesthetic: movement, acting out, physical activities o Musical: rhythm, rhyme, music, environmental sounds Are there physical, audio, visual or other adaptations the students o Linguistic: reading, playing word games, making up poetry or may need? stories ______o Logical: explore patterns and relationships, experimentation, Specific Tools Your Class Utilizes for Communication: problem solving ______

PROGRAM GOALS: Please describe the goals for your students’ museum experience.

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