Pollution Detectives Traveling Lab Application Form

Print this page and return this form with payment to:
Education Department
The Children's Museum of Memphis
2525 Central Avenue
Memphis, TN 38104-5926

Or fax to:
901-458-4033

To make a reservation using a credit card:
Online Pollution Detectives Lab Form

Rental Period From: __________ To: __________
School _________________________
Teacher _________________________
School address _________________________ School zip _________________________
School phone _________________________ Home phone _________________________ Other phone _________________________
Email _________________________
School hours __________ am to __________ pm
Number of classes participating: __________ Total number of students: __________

Memphis City Schools, Shelby County Schools & Other Schools located in Shelby County fill in this section only.

Please check one of these categories:
_____ Memphis City School
_____ Shelby County School
_____ Other School Located in Shelby County

I would like to keep the Lab for _____ weeks.

Please read the following carefully and sign below:

• I will return the Lab on time with the completed assessment form to the museum.

• I will pick the Lab up on: __________ and return it on: __________.

• If any Lab items are missing or damaged I will notify the museum's education staff immediately. I will return all items cleaned and in good condition.

• I am responsible for missing or damaged items, and may be asked to replace them (depending on value).

All Other Schools located outside of Shelby County must fill in this section.

_____ Other School

I would like to keep the Lab for _____ weeks at $25 per week for a total cost of $ __________.

Method of Payment:
_____ Check
_____ MasterCard
_____ Visa
_____ Discover

Card number _________________________ Expiration date _________________________
Signature _________________________

Please read the following carefully and sign below:

• I have paid $ __________ for _____ weeks for the Lab.

• I will pick the Lab up on: __________ and return it on: __________.

• If any Lab items are missing or damaged I will notify the museum's education staff immediately. I will return all items cleaned and in good condition.

• I am responsible for missing or damaged items, and may be asked to replace them (depending on value).

• I will return the Lab on time with the completed assessment form to the museum.

Teacher Signature: ______________________________ Date: __________

For further information:
Email Education Manager or call 901-458-2678, ext. 250