Transportation Scholarship Application – Eckley Miners' Village Museum

School *Only schools are eligible for the CCX Transportation Scholarship.

School District *

Contact Name *

Email Address *Please be sure to double-check email addresses for accuracy as status notifications will be delivered via email.

Phone *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Title-I Eligible *Title-I eligibility is not required, but Title-I eligible schools will receive precedence.

Proposed Date of Field Trip *

Arrival Time *

Hours

Minutes

Departure Time *

Hours

Minutes

Number of Students *

Number of Chaperones *

Transportation Company *Please provide possible transportation companies you'll utilize. This can be changed later.

Scholarship Amount Requested *If approved, an invoice from the transportation company will be required. We will pay the company directly, and send the school contact proof of payment.

Acknowledgement: I understand that the CCX Scholarship is to cover transportation for a field trip to Eckley Miners' Village only. I also understand that this form is not a reservation and/or confirmation for your visit. Please contact the Museum Educator, Nicole Negron, at nicnegron@pa.gov to reserve your group's visit. *

Yes.

Grade Levels Attending