Classroom Collections Reservations

Name

First Last

School Name*

School Address*

Street Address Address Line 2 City State ZIP Code

Home Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Subject taught*

Grade Level Taught*

RESERVATION

Anne Frank Collection - $25.00

Price: $25.00 Quantity:

Night Collection - $25.00

Price: $25.00 Quantity:

Local Survivor Collection - $25.00

Price: $25.00 Quantity:

Date Range Preference #1*

Date Range Preference #2*

Date Range Preference #3*

Total

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

IMPORTANT INFORMATION ABOUT YOUR RENTAL: Collections may be picked up in the MCHE office after 8:30 am on the first day of each loan cycle and must be properly assembled and returned no later than 5:00 pm on the last day of the cycle. In requesting the loan of these resource collections, the teacher named above and/or the school or school district agree(s) to the following: Chests will be housed in the classroom of the requesting teacher and will remain secured when unsupervised. All copyrights will be honored. I agree to the conditions stated above and understand that I am financially responsible for replacement of missing or damaged materials from the chest.