NAME: ___________________________________________________________________
ADDRESS: ________________________________________________________________
CITY, STATE, ZIP: _________________________________________________________
TELEPHONE #: ___________________________________
EMAIL: ____________________________________________________________________
PROGRAM TITLE: ________________________________________________________
PROGRAM DESCRIPTION: ___________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
AGE GROUP: __________________________________________________
DATES: _________________________________________________________
DAYS: ___________________________________________________________
TIMES: ___________________________________________________________
FACILITY REQUIREMENTS: Location? Room # ? (i.e., need a sink, outdoors, gym, etc.)
______________________________________________________________________________
MINIMUM ENROLLMENT: ____________
MAXIMUM ENROLLMENT: _____________
SUBCONTRACTOR’S FEE (be very specific, state if it is a per participant fee, hourly rate, etc.
We will add our fee onto yours in order to cover our costs):
_______________________________________________________________________________