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Education Program Request Form

Complete this form if you would like to request an education program for school (including home school) students. We will reply to your request in email as soon as possible

This is NOT a confirmation of a booking, an Education Officer will reply to your request and confirm dates, time and details of your booking.

Email address and Phone number (numerals only) are required for correspondence. Please check the box if you do not wish to receive marketing material.

School

School Required
Teacher in Charge Required
Email Required
Recieve promotional material Check this box if you do not wish to receive marketing material from the State Library of WA	No
Phone Work Required
Phone Mobile
Fax
Have you visited with students before?	Yes No
How did you hear about us?	Brochure Event (eg Scitech expo) Referral - Art Gallery Refererral - Museum State Library Website Word of Mouth

Group Details

Proposed date
Session Time: Please select your preferred session time.	9.45am - 10.45am 11am - 12 noon 12:15pm - 1.15pm
Year Level Required
No. of students Required
No of teachers/adults
Students will special needs	Yes
Please provide details Lift and other access facilities are available on site.
Course/ Topic of Study Required

Program

Program
Will students be staying on for additional study after the program?	Yes No Unsure
Will students also visit Art Gallery and/or Museum?	Yes No

Page last updated: Wednesday 7 March 2012