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Student Reservation Form




* = Required Fields

School Information

* Name of School:
District:
* Address:

* City:
* State/Province:
* County:
* Zip/Postal Code:
* Country:

 

Time Required for e-Missions
Visit www.e-missions.net for more information

Operation Montserrat: 120 minutes Moon, Mars, and Beyond: 90 minutes
Space Station Alpha: 90 minutes
Fire Scene Investigation: 90 minutes Target Moon: 90 minutes
Storm-e, New York/Dayton: 60 minutes M.A.R.S.: 90 minutes
Cyber Surgeons: 60 - 90 minutes
Hurricane Alert!: 90 minutes

 

e-Mission Information

* Teacher's Name:
* Phone: (XXX-XXX-XXXX)
* Email:
Time Zone:
Good Time to Contact You: (ex: 9:00am - 3:30pm, Mon - Fri)
* e-Mission Choice (See Times Above):
Number of Students:
Grade Level(s):
Preferred e-Mission Schedule: (please provide first two choices below)
* 1st Choice Date: (mm/dd/yyyy)
* Start Time:
* End Time:
* 2nd Choice Date: (mm/dd/yyyy)
* Start Time:
* End Time:
Have you gone through our Teacher Training Program?   Yes     No
Comments or Essential Requirements

 

Invoicing Information

Send Invoice To:
Attn:
Email:
Street Address:
City:
State/Province:
Zip/Postal Code:

 

Technical Information

Technology Coordinator:
Office Phone: (XXX-XXX-XXXX)
Cell Phone: (XXX-XXX-XXXX)
Email:
Good Time to Contact:

 

How will you be connecting with the Challenger Learning Center?
(please provide a connection address if you know it)

IP with Video Conferencing Equipment:
IP with Computer & Webcam (Net Meeting):
Other:


If you have any questions, please feel free to contact:
Lori Kudlak
Assistant Director
1-304-243-8729
lkudlak@wju.edu
or Laura Ondeck
Lead Flight Director
1-304-243-2029
londeck@wju.edu
For technical questions and assistance, please contact:
Dan Murphy
Technical Coordinator
1-304-215-5114
dmurphy@wju.edu

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