MNCH Traveling Trunk Request Form

Please complete this form at least two weeks in advance of your desired reservation date.

If you have any questions, you can review the information on our website or contact mncheducation@uoregon.edu.

Group leader/contact

School/organization name

Name of School District (if applicable)

Phone

Mailing Address

City/Town

State/Province

ZIP/Postal Code

I would like to reserve the trunk for:

1 week

2 weeks

First Choice Reservation Date: Select the Monday you would like to begin using the trunk.

Second Choice Reservation Date: Select an alternative Monday you would like to begin using the trunk.

Grade Level of Students Served by Trunk

Approximate Number of Students that will be Served by Trunk:

Where is your school located?

Eugene/Springfield

Rural area outside Eugene/Springfield

	Our school qualifies for a fee waiver because (check all that apply):
Title 1 status	Title 1 status
Over 40% of students qualify for free and reduced lunch	Over 40% of students qualify for free and reduced lunch
Rural Location	Rural Location
None of the above	None of the above

I will pay for the trunk:

With a fee waiver

With a card over the phone before pick up

With cash, check or card when I arrive to pick it up

Other information I would like MNCH to know:

Contact Info