Name *

First Name

Last Name

Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Grade levels attending *

5th grade

6th grade

7th grade

8th grade

9th grade

10th grade

11th grade

12th grade

Would you like to request the use of our outdoor picnic area? *

Please note that not all requests to use the outdoor picnic area can be granted.

Yes

No

Are you interested in a bus subsidy? *

(up to $100 per bus)

Yes

No

Did you know that group donations to our 501(c)3 organization are tax deductible? *

Yes

No

Would you like to be included on our email list to receive information about upcoming programs and events at HMMSA? *

Yes

No