Derby Workshop Program Request Form

Name *

First

Last

Email *

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Scout Rank *

Troop/Pack Number *

Total # of Students *

Min. of 10 - Max of 12. larger groups can be split into multiple time slots. If you have less than 10 students it is still possible to book but each student's cost will be higher to reach the minimum cost of $250 per program.

Total # of Adults *

One adult must stay with the students at all times. Additonal adults are allowed at no cost with a max of one adult per child due to space limitations.

Prefered Date & Time

Programs can be booked weekdays afterschool, Saturdays 10am-5pm or Sundays 12pm-5pm. Programs will run for 2 hours after the start time.

1st Preference Date / Time *

Date

Time

2nd Preference Date / Time

Date

Time

3rd Preference Date / Time

Date

Time

Todays Date: *

*Requests are not guaranteed program reservations. Once the form is submitted, you will be contacted via email in 3-5 business days. Requests are processed in the order they are recieved.

Notes: