FIELD TRIP REQUEST FORM



1600 Ken Thompson Pkwy.

Sarasota, FL 34236

Fax: 941-388-4381

Website:

MOTE ISLAND QUEST REQUEST FORM

Reservations may only be made by completing this form and faxing or mailing it to the address listed above. Your booking will be confirmed in writing by e-mail, fax, or regular mail. Spaces are limited and prepayment is required.

Name of Child Participants: Age: Grade:

Age: Grade:

Age: Grade:

Name of Parent or Guardian:

E-mail:

Phone Number: Day ( ) Evening ( )

Home Address: City: State: Zip:

Local Address (if different): City: State: Zip:

MOTE MEMBERS:

Name on Membership Card: Member #: Expiration Date:

|Program Cost |Mote Members |Non-members |

| |$125 |$150 |

|One Course, includes: |per child |per child |

|12 Total Program Hours: 3 Consecutive Saturday Afternoons from 1 p.m. to 5 p.m. | | |

|All Lab, Field, and Craft Materials | | |

|A Light Snack | | |

| |1 |

By Check: Please make checks payable to: Mote Marine Laboratory. Amount Enclosed: Check #:

By Credit Card: Please circle your credit card of choice. VISA MASTER CARD AMERICAN EXPRESS DISCOVER

Card #: Expiration Date: ____/____ (mm/yy) Amount:

Name as it appears on card: Signature:

MAIL: Mote Marine Laboratory, Attn: Debbie Tidwell, 1600 Ken Thompson Parkway, Sarasota, FL 34236

FAX (Credit Card payment only): (941) 388-4381

**No refunds unless Mote cancels the program. For more information call (941) 388-4441 x229 or e-mail educate@.

|Mote Education Internal Use Only: Date received ______________ Initials _____ Amount: ______________ Check #: _______________ |

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