In‑Person Tour, Dialogue, & Transportation Grant Application

Programs are approximately 3 hours and include a 90‑minute tour and a dialogue with a Holocaust survivor or descendant.

Transportation grant questions are located at the bottom of this form.

Name of School
Eligibility Checklist (All schools except San Diego schools must meet at least one of the following requirements to be considered. San Diego schools can leave blank.)

Eligibility Checklist (All schools except San Diego schools must meet at least one of the following requirements to be considered. San Diego schools can leave blank.) Title I School Program At least 50% of my students receive free or reduced lunch None of the above
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
County
School District
School Phone Number School Phone Number - ### - ### ####
Teacher Phone Number Teacher Phone Number - ### - ### ####
Email
Teacher/Chaperone Name (for day of visit)
Teacher/Chaperone Cell # (for day of visit) Teacher/Chaperone Cell # (for day of visit) - ### - ### ####
Principal Name
Subject/Course Title
Number of students (maximum capacity 160 students)
Age Level

Age Level 4th Grade 5th Grade 6th Grade 7th and 8th Grade High School College Other
Field Trip Date Requested Field Trip Date Requested / MM / DD YYYY
Alternative Field Trip Date Requested Alternative Field Trip Date Requested / MM / DD YYYY
Tour Time Requested (San Diego schools must choose an arrival time between 11:00 and 2:00 pm)

Tour Time Requested (San Diego schools must choose an arrival time between 11:00 and 2:00 pm) 10:00 AM - 1:00 PM 11:00 AM - 2:00 PM 1:00 PM - 4:00 PM Other
Tell us about your class:
Rate your students' knowledge of the Holocaust

Rate your students' knowledge of the Holocaust Excellent Good Satisfactory
Describe your class's familiarity with the Holocaust
Please list any Holocaust related materials (books, films, etc.,)
How did you hear about Holocaust Museum LA?
Has your class ever visited Holocaust Museum LA before? If so, when?
Transportation Grant (Optional)

Complete this section to be considered for transportation grant funding assistance.
Number of buses needed:
Estimated Total Cost:
I certify that my school is a Title I school or school with at least 50% of students who receive free or reduced lunch and will be granted $800.

I certify that my school is a Title I school or school with at least 50% of students who receive free or reduced lunch and will be granted $800. Yes
I am requesting more than $800 per bus. I will be submitting a copy of transportation expenses for reimbursement.

I am requesting more than $800 per bus. I will be submitting a copy of transportation expenses for reimbursement. Yes
Have you ever received a transportation grant from Holocaust Museum LA?
Teacher's Initials (Your initials to indicate your agreement to complete a teacher feedback form after your visit)
Principal's Initials
Please tell us your reasons for applying for a transportation grant.
Bus/Check Payable To:
Bus/Mailing Address Bus/Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Bus/Financial Name Bus/Financial Name First Last
Bus/ Email
Bus/Phone Bus/Phone - ### - ### ####
Bus/I certify that to the best of my knowledge and belief all of the information on this form is correct.

Bus/I certify that to the best of my knowledge and belief all of the information on this form is correct. Correct
Bus/Type name to sign.

In‑Person Tour, Dialogue, & Transportation Grant Application

In‑Person Tour, Dialogue, & Transportation Grant Application

Transportation Grant (Optional)