Central PA’s Nonprofit Center for the Arts

Surgery LIVE! Visit Request Form

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NOTE: You must have paid for your Surgery Live! program for this RSVP form to be valid. If you have not already paid, please visit whitakercenter.org/surgery-live to pay for your registration before completing this form. Surgery Live! is available on a first-come, first-served basis.

Visit Details

Date Requested *

School Name *

District *

School Address *

Lead Teacher Name *

Phone Number *

Email Address *

Grade Level(s) *

Number of Students - (Please use the attendance number you paid for.) *

Number of Adults - (Please use the attendance number you paid for, including 1 free lead.) *

School Address *

Type of School *

Notes/Special Needs:

Arrival / Departure details:

Arrival Location *

Type of Vehicle (Please choose all that apply) *

Bus

Van

Cars

Number of Vehicles *

Arrival / Departure notes:

Schedule

Arrival Time - (3rd Street doors open at 8:30am. Program begins at 9:00am sharp.) *

Departure Time - (Program is scheduled until 11:30am, however it may end earlier or later due to the nature of live surgery.) *

Lunch

If staying after Surgery Live!, what you would like to do? (i.e. Visit Science Center, eat lunch offsite, view film, etc.)

Will your group visit the Wonders Store?

Planning notes:

3rd Street entrance is the only door open prior to 9:30am.
You must have a ratio of 1 adult (or more) per 10 students.
If the Lead planning teacher will not be onsite, please indicate who the Lead Onsite Teacher will be in the "Notes" section.
Please let us know in advance if you have chaperones arriving separately from your busses or vans; for security reasons, unexpected additional adults will not be allowed to join your group.

Please respond to the following: *
Required Field

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Surgery LIVE! Visit Request Form

Visit Details

Arrival / Departure details:

Schedule

Planning notes:

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