Thursday, February 26, 2015

TICKET PRICE: $10.00 General Audience

10:30 am - 12:30 pm in IBLA/ runtime 122 mins

COMPLIMENTARY BUS TRANSPORTATION APPLICATION

Teacher Name: _____________________________________________________________________ Grade/Subject Area Taught: ___________________________________________________________ Phone Number: _____________________________________________________________________ Email Address: ______________________________________________________________________ School Name: _______________________________________________________________________ Principal Name: ______________________________________________________________________ School Address: ______________________________________________________________________ ___________________________________________________________________________________ 501C3 # (if applicable)_________________________________________________________________ School Phone Number: _______________________ Teacher Cell Phone: ________________________ Percentage of Student body listed as Low Income: __________________________________________ A copy of your school’s Illinois School Report Card downloadable from the CPS Office of Research, Evaluation and Accountability http://www.cps.edu/SchoolData/Pages/SchoolData.aspx

Please Fax This Form to 773.947.0677 ATTN: Education Department, Complimentary Bus Transportation Grant

All Materials are required for consideration.

For Office Use Only:Received date ___________________________

Decision Notification _____________________

Initial Response Date______________________

Notes_______________________________________________________________________________

740 E. 56th PlaceChicago, IL 60637773.947.0600 phone773.947.0716 faxwww.dusablemuseum.org DuSable Bust Sculpture: Erik Blome

GROUP VISIT RESERVATION FORM The DuSable Museum of African American History welcomes groups of all ages. Reservations are required for all groups larger than 10 people or small groups requesting educational programming. Please make your reservation for guided tour, self guided tour, treasure hunt, education class, or matinee at least 3 weeks prior to your visit. Please note: chaperones and teachers are responsible for supervising groups. Student groups (K-12) must have one adult chaperone per every 10 students. All educational programs and tours are set to begin at 10:30am. Please review the attached “Field Trip Policies” sheet before visiting to ensure an enjoyable experience.

***Return page 1 by email to whamilton@dusablemuseum.org or fax 773.947.0677*** CONTACT INFORMATION Name of School/Group/Address Age(s) Lead Contact’s Name Lead Contact’s Email Lead Contact’s Phone # of Attendees # of Chaperones

Field Trip Date and Time Field Trip Date Field Trip Time

February 26th 2015 10:30am-12:30pm

Check all that apply: ( ) ESL ( ) Special Needs ( ) Wheelchair Access ( ) Other

MUSEUM EXPERIENCE: PLEASE CHECK ALL THAT APPLY CPS Schools, Illinois Public Schools, and Park District Groups are given free admission Experience Check Total Cost SELMA film screening $6.00 per person

GROUP RESERVATION FORM

COMPLIMENTARY BUS TRANSPORTATION APPLICATION

FIELD TRIP POLICIES

Registration • View information on Field Trips, Matinees, Programs, and related events at

http://www.dusablemuseum.org/education/programs • Pre-registration is required for all teachers, chaperones, and students at least 3 weeks in

advance of visit. • Field trips and student programs are only available for groups of 10 or more. • Registration for groups is required on Museum Free Days. • We reserve the right to cancel your program if you are 30+ minutes late without notification.

Chaperones

• Pre K groups must be accompanied by a minimum of 1 adult for every 5 students • K through 12th grade students must be accompanied by 1 adult for every 10 students • Adults in excess of the ratio not included in pre-registration will be subject to full admission

costs upon arrival • Students must remain with their chaperones at all times. Failure to adequately supervise your

group may result in the group being asked to leave the Museum Conduct

• Back packs or large purses are not allowed into the Museum galleries • Flash photography is not permitted inside of the Museum galleries • Horseplay and/or roughhousing are not permitted inside of the Museum galleries

Payment

• To cancel or revise your reservation email whamilton@dusablemuseum.org • Cancellations or changes to reservation must be made 14 days prior to scheduled visit to receive

a refund. Incidentals

• The DuSable does not have a lunch room facility but can store lunches that do not require refrigeration.

• Large backpacks and purses are not allowed inside of the galleries • Food and drink are not allowed inside of the galleries • Photography is not allowed inside of the galleries

I understand the rules and policies presented and I will share them with my students and chaperones. ________________________________________________________________ Signature

740 E. 56th PlaceChicago, IL 60637773.947.0600 phone773.947.0716 faxwww.dusablemuseum.org DuSable Bust Sculpture: Erik Blome

FIELD TRIP POLICIES