Survey - Education Humane IQ Program Request - Humane Society of Missouri

Character Education Program with the Humane Society of Missouri

PLEASE NOTE: Completion of this form does NOT confirm your field trip. A representative from HSMO's Education Department will contact you to confirm all details.

At this time, Education Programs take place at HSMO's Macklind Ave. Headquarters ONLY. Bus transportation to HSMO for 5th or 6th graders for the first part of program is provided free of charge.The class will be held from 10:00am - 12pm on Tuesdays through Fridays.

Please complete the following information below to help us schedule your program:

*1.

Question - Required - Name of school and grade:

*2.

Question - Required - School Address and where the bus should pick-up your group.

*3.

Question - Required - School District

Please choose the preferred (3) sets of dates for your two-part program. Ex. if Part A is on a Tuesday, Part B would be the following Tuesday.

Part A Education kids of our program takes place at the Humane Society of Missouri, 1201 Macklind Ave. We provide FREE round-trip bus transportation for fifth or sixth grade students to our facility.

Part B of the program is an all-school assembly presented by HSMO's professional educators and your students.

*4.

Question - Required - Please enter 3 sets of dates one week apart: Part A (visit to the Humane Society) Part B (School Wide Assembly)

(Maximum response 255 chars, approx. 5 rows of text)

*5.

Question - Required - Approximate number of attendees (do not include chaperones) for Part A (Visit to HSMO) of your oldest grade.

*6.

Question - Required - How many chaperones will be attending? (1 per 10 students)

*7.

Question - Required - Number of K - 6th graders for Part B (school assembly) 45 min. 10-10:45 a.m.

*8.

Question - Required - Any special needs or requests we need to be aware of in order to ensure the best experience for your group? If not, please enter NONE, as this is a required field.

9.

Contact Information


*	First Name: Required
*	Last Name: Required
*	Email: Required
*	Phone Number: Required
	Yes, I would like to receive e-mail from Humane Society of Missouri - http://www.hsmo.org
	Yes, I would like to receive postal mail from Humane Society of Missouri - http://www.hsmo.org

*10.

Question - Required - Please enter your cell phone no.

*11.

Question - Required - Contact position (i.e. teacher, counselor, school admin, etc.)

12.

Question - Not Required - Do you have any other questions about your visit?

13.

How did you hear about HSMO's Education Programs?

(Select one of the available choices or enter a different value.)
Question - Not Required -