Intake Form

Intake Form
School & Service Information
School Name*
School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Service*

New School ProgramReturning School ProgramSurveyWorkshopOther
Date of Service*
Please provide the date of service. If you don't have a firm date, let us know if it will occur in the next 30 days.

Financial Information
Entity Responsible for Payment
If other than the school. Could be a district, PTA, or 3rd Party
Funding Source
If other than the school. Please be specific, i.e. Federal ESSER or EANS, Title 2, PTA, etc
Authorized Representative Contact Information

(HOS, principal, district, etc)
Authorized Rep Name (please include any preferred prefixes or suffixes i.e. Mr, EdD, etc.*

First NameLast Name
Authorized Rep Title*
Authorized Rep Email*
example@example.com
Authorized Rep Phone Number*
Please enter a valid phone number.
Contact for payment (accounts payable, business office):*

Authorized RepresentativeDifferent Person
Contact for Payment Name*

First NameLast Name
Contact for Payment Title*
Contact for Payment Email*
example@example.com
Contact for Payment Phone Number*
Please enter a valid phone number.
What other information do you need from us to initiate payment?

Vendor ApprovalPurchase OrderCertificate of InsuranceW9 Tax Form for Challenge SuccessOther
Next Steps

Upon completion of this intake form, you will receive a Letter of Agreement and an invoice with payment due 30 days after invoice date or due upon receipt if service is scheduled within the next 30 days.
Next Steps for School Program Payment

Upon completion of this intake form, you will receive a Letter of Agreement for signature and an invoice with payment terms of 50% of the total fee due 30 days from invoice date and the final 50% payment due August 15, 2022.
Delivery of services is contingent upon payment by the due date. Please let us know if you have any questions or special circumstances regarding meeting our financial terms. Share a specific contact name and email to discuss further.
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Intake Form

School & Service Information

Financial Information