Survey - Virtual Field Trips for Students

After this request form is completed and returned we will contact you to confirm your Virtual Field Trip.

Contact Information

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Name:

First Required	Last Required

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Email: Required

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Street 1: Required

Street 2:

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City/State/ZIP:

City Required	State Required	ZIP Required

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Phone Number: Required

If you respond and have not already registered, you will receive periodic updates and communications from Simon Wiesenthal Center.

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Question - Required - Position/Title:

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Question - Required - School / Organization:

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Question - Required - Preferred Date 1:

Month

Day

Year

Question - Not Required - Preferred Date 2:

Month

Day

Year

Question - Not Required - Preferred Date 3:

Month

Day

Year

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Question - Required - Total number of students who we would like to schedule for.:

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Question - Required - Select the modules you are interested in booking:
Please make at least 1 selection from the choices below.

	Anne Frank: A Fascinating Look at the Real Anne
	Tolerancenter: Contemporary Lessons
	Holocaust History Session: Youth Voices and Resistance
	Combat Hate
	Holocaust Survivor Personal Testimony

The fee for the Virtual Field Trips is $150.00 per module for a class of 25-30. Payment can be made by check, Visa, Mastercard, and American Express.

Limited grant funds are available, please contact us for details

This form is only to request a Virtual Field Trip and is not a confirmation of your program.

We will send you confirmation materials upon review of your application. If you do not hear from us please contact mlynn@wiesenthal.com to confirm that your application was submitted.

For additional information and questions please call (310) 772-7639 or e-mail mlynn@wiesenthal.com.