School Name *

Address *

City *

State *
AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip *

Phone *

Fax

E-mail *

Name of Principal *

Name of Classroom Teacher *

For students in the applying classroom only (If “none,” please select less than 25%)

Students Receiving Free or Reduced Lunches *
– Select –Less than 25%25-50%51-75%More than 75%

Language *

English

Spanish

Other

Explain how the students from your classroom will benefit from a field trip to Kohl Children’s Museum *

Number of Children in Classroom *

Documentation (500k file upload size limit) *

Please attach an official school document on school of district letterhead confirming the percentage of children at risk of academic failure within the entire school (percentage of children on free or reduced lunch is acceptable).