Buchanan Music Department

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Disneyland Trip Form

Student Name *
Student Name
Parent/Guardian Name *
Parent/Guardian Name
Parent/Guardian Phone *
Parent/Guardian Phone
Payment Options *
If you requested financial assistance under ‘Payment Options’ above, please enter the amount you will pay in full by Friday, May 11, 2018. **PLEASE NOTE** The greater the number of requests and/or the amounts requested, the greater the financial burden on our program increasing the risk that the trip may be canceled.
$
We would like to donate the following amount in addition to the trip fee to assist those in need. (Please include this amount in your check or the amount you pay with your credit card. Thank you for your generosity!)
$
Do you have a Disneyland Signature or Signature Plus Annual Pass? *
Signature & Signature Plus Annual Passports are valid on June 9th. Your trip cost is $75.00. You will still receive meal vouchers. Please make sure you bring your pass on the trip!
Payment Type *
Name on the check or credit/debit card:
Name on the check or credit/debit card:
So we can match the payment to the student.
Please complete the following section if you are interested in chaperoning this trip. Otherwise, scroll to the bottom and press SUBMIT DISNEYLAND TRIP FORM.
We will contact you if you are selected to chaperone. Chaperones must ride the bus to & from Disneyland & pay the trip fee of $180.00 (Do not pay until you have been notified that you have been selected to chaperone).
Chaperone Name
Chaperone Name
Chaperone Mobile Phone
Chaperone Mobile Phone