Traveling Trunk Registration Form
Name: ________________________________________________ School: ______________________________________________ School District: _____________________________________ Street Address: ______________________________________ City: __________________ State: ______ Zip:___________ Phone:____________________ Email:____________________ Fax: ___________________ Dates preferred: 1st Choice: _____________ 2nd Choice: _______________ Are you a: (check all that apply) __________ Museum Educator? Grade level __________ __________ Art teacher? Grade level __________ __________ Classroom Teacher? Grade level __________ __________ Subject Area Teacher? Subject __________ Grade level __________ __________ Gifted Education Teacher? Grade level __________ __________ Special Education Teacher? Grade level __________ Trunk Services Requested: (check all that apply) __________ Rent a trunk for a month: $75 per month __________ Museum educator $75 __________ Rent a trunk for one day: $100 __________ $25 educator's fee for each additional class period for the daily rental __________ Security Deposit $100 Total Fee Enclosed ___________ Check #: __________________ Please make check payable to the James A. Michener Art Museum. Signature of person responsible for trunk: ______________________________________________________