Chartwells Experience Request Form

1.	School Name:*

2.	School Number:*

3.	Principal Name:*

4.	Number of students participating:*

5.	Grade level of students participating:*

6.	Do the students participating have current media releases?*

Contact information of person requesting the activity or event:*

Name
Phone Number
Email

8.	Type of activity or event you are requesting:*

Ideal date and time for your requested activity or event:*
Please provide your top three date and time preferences.
Enter at least 1 response and no more than 3 responses.

Date
Time
Date
Time
Date
Time

10.	Preferred location for activity or event:* (i.e. media room, gym, cafe, etc.)

11.

FOR FIELD TRIPS ONLY:

Number of Chaperones
Will you need bus transportation? If yes, how many buses will you need?
Will you be needing bag lunches from your cafe? If yes, how many?

12.

Please include your school's social media information below:
Handles or links to your pages (i.e. @ChartwellsDuval or https://twitter.com/chartwellsduval)

Facebook
Twitter
Instagram

13.	Do you have any additional comments, questions or concerns? Please list any special needs or requests that may not have been stated in the above form.

Chartwells Experience and Nutrition Education Request Form