Portable Museum Request Form – Museum of History & Industry

1School / Org

2Contact

3Scholarship

4Portable Museum

5Comments or Requests

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School / Organization Info

School / Organization Name*

School District (if applicable)

School / Organization Phone*

School / Organization Address*

Street Address Address Line 2 City State ZIP Code

Contact Info

Contact Name*

First Last

Contact Email*

Contact Phone*

Contact is the:*

Teacher or Instructor

Parent or Volunteer

Administrator

Other

Scholarship

Are you applying for our scholarship program?*

No thanks

Yes, we are a Title I school.

Yes, we are a federally funded Headstart or ECEAP program

Yes, we are a public school where 40% or more of enrolled students qualify for government-subsidized meals

Yes, we are a youth program receiving 5% or more of its funding from government sources

Yes, we are a youth program with 40% or more of enrolled children receiving some form of public assistance

Please explain in 1-2 paragraphs how your students would benefit from this scholarship assistance and from MOHAI's resources/programs:*

Portable Museum Program Information

How many portable museums would you like to rent?

Portable Museum Program 1

Select the Portable Museum Program topic:*

Click here to learn more about these options

Exploration & Trade Trunk

Settlement in Puget Sound Trunk

Coast Salish Culture Trunk

The Years of Growth & Change Trunk

The WWII Homefront Experience Trunk

Seattle Innovations Trunk

Discovering Seattle Stories Early Learning Kit

The Years of Growth & Change Dig Deep CBA Kit

Century 21 Exposition Kit

Grade Level*

How many students will be using this resource?*

How many classrooms will be using this resource?*

Rental Duration*

MOHAI generally cannot accommodate short-notice rental extensions

2 weeks (minimum rental period)

3 weeks (+ $25)

4 weeks (+ $50)

5 weeks or more (additional fees apply)

Preferred Pick-up Date*

Please indicate the date you plan to pick up the rental at MOHAI, not the first date of classroom use. Pick-ups must occur during museum hours (daily, 10 am-5 pm).

MM slash DD slash YYYY

Alternate Pick-up Date*

MM slash DD slash YYYY

Portable Museum Program 2

Select the Portable Museum Program topic:*

Click here to learn more about these options

Exploration & Trade Trunk

Settlement in Puget Sound Trunk

Coast Salish Culture Trunk

The Years of Growth & Change Trunk

The WWII Homefront Experience Trunk

Seattle Innovations Trunk

Discovering Seattle Stories Early Learning Kit

The Years of Growth & Change Dig Deep CBA Kit

Century 21 Exposition Kit

Maritime Kit

Grade Level*

How many students will be using this resource?*

How many classrooms will be using this resource?*

Rental Duration*

MOHAI generally cannot accommodate short-notice rental extensions

2 weeks (minimum rental period)

3 weeks (+ $25)

4 weeks (+ $50)

5 weeks or more (additional fees apply)

Preferred Pick-up Date*

Please indicate the date you plan to pick up the rental at MOHAI, not the first date of classroom use. Pick-ups must occur during museum hours (daily, 10 am-5 pm).

MM slash DD slash YYYY

Alternate Pick-up Date*

MM slash DD slash YYYY

Portable Museum Program 3

Select the Portable Museum Program topic:*

Click here to learn more about these options

Exploration & Trade

Settlement in Puget Sound

Coast Salish Culture

The Years of Growth & Change Trunk

The WWII Homefront Experience Trunk

Seattle Innovations Trunk

Discovering Seattle Stories Early Learning Kit

The Years of Growth & Change Dig Deep CBA Kit

Century 21 Exposition Kit

Maritime Kit

Grade Level*

How many students will be using this resource?*

Please enter a number greater than or equal to 0.

How many classrooms will be using this resource?*

Please enter a number greater than or equal to 0.

Rental Duration*

MOHAI generally cannot accommodate short-notice rental extensions

2 weeks (minimum rental period)

3 weeks (+ $25)

4 weeks (+ $50)

5 weeks or more (additional fees apply)

Preferred Pick-up Date*

Please indicate the date you plan to pick up the rental at MOHAI, not the first date of classroom use. Pick-ups must occur during museum hours (daily, 10 am-5 pm).

MM slash DD slash YYYY

Alternate Pick-up Date*

MM slash DD slash YYYY

Comments or Requests

Do you have any comments or special requests for your rental(s)?

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