Program Request Introductory Questionnaire Sheet

Program Request Introductory Questionnaire Sheet
Proposed Program Start Date

Month Day Year Hour Minutes AM/PM Option
Try to answer as many relevant questions on this sheet as possible. With the answers to these questions, we should be able to get a good picture of what you need before contacting you.
Point of Contact
Contact Person *

First Name Last Name
E-mail *
Briefly describe the need for the program:
Briefly describe the desired goals and objectives of the program:
Type of Program

What type of program are you needing?
Non-profit partnership School based program Community/out of school time program
Additional Comments:
Should be Empty:

Point of Contact