EXHIBITION
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Education Program Booking Request Form PERC TUCKER REGIONAL GALLERY 29 MAY – 12 JULY 2015
CONTACT DETAILS School name: Address: Teacher name: Phone:
Mobile:
STUDENT DETAILS Primary (Activity books provided) Year Level: Secondary (Education resource and worksheets provided) Year Level: Number of teachers/supervisors:
Number of students:
OTHER: Special Requirements or Accessibility Requirements:
VISIT DETAILS Preference 1: Date: Time:
Preference 2:
Length of visit:
Date: Time:
EXHIBITION
EXHIBITION
Brought to you by Glencore
Education Program Booking Request Form PERC TUCKER REGIONAL GALLERY 29 MAY – 12 JULY 2015
Choose an activity or combination of activities for your students. Please tick appropriate fields: Activity:
Guided Tour (Approx. 30 mins)
Self-guided Tour
Wearable Art Workshop (Approx. 30 mins)
Visit focus Please provide information if you would like to focus your visit on a concept or subject:
Self-Guided Tour To assist with programming please indicate intended day and estimated times you may be undertaking self-guided tours if applicable. Mon
Tues
Wed
Thurs
Fri
AM PM TIME:
Would you like education material sent prior to your visit?
Yes
No
Please return this form in person, post or via email to the Perc Tucker Regional Gallery to secure your booking.The latest information about exhibitions and education programs are available here: www.bit.ly/ptrgtcc You are providing personal information which will be used for the purpose of delivering services and carrying out council business. Your personal information is handled in accordance with the Information Privacy Act 2009 and will be accessed by persons who have been authorised to do so. Your information will not be given to any other person or agency unless you have given us permission or the disclosure is required by law.