Next step to being the change workshop program request form




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NEXT STEP TO BEING THE CHANGE WORKSHOP

PROGRAM REQUEST FORM
Thank you for taking the time to complete this form! This is the first step in booking your Next Step to Being the Change Workshop, and it is important for the success of your workshop to complete the entire questionnaire.
To use this form, press the TAB key to move forward from field to field. When you are done, be sure to save this document with the name of your organization (such as “Northern California Circle of Change.doc”) to your computer and then return via email to office@challengeday.org. Also, please be sure to print a copy of it for your records.
When we receive the completed form, we will contact you to confirm the dates and begin the contract and coordination/coaching processes.
Again, thank you. You are the change, and we are excited to be on this journey with you!

SCHOOL / ORGANIZATION AND PROGRAM DATES REQUESTED



Organization Name:      

Street:      

P.O. Box (if applicable):      

City:      

State:      

Zip or Postal Code:      

Country:      

Requested Program Day Date(s) – enter a specific date or range of dates in each field for 1st, 2nd, and 3rd choices:

1st Choice:      

2ndt Choice:      

3rd Choice:      

Program requested:  Next Step to Being the Change Workshop 
Name of Person completing form:      

Date Form Completed and/or Revised:      

Contact Phone Number:      

Best Days/Times to contact:      

Role/Relationship to Organization:      

(teacher, administrator, parent, community member, etc.):

CHALLENGE DAY / NEXT STEP HISTORY

How many, if any Challenge Days have you had in your area in the past?      

How many, if any Challenge Days do you have booked in your area?      

How many Next Step to Being the Change Workshops have you had in your area?      

CONTACTS


  1. Coordinator Name:      
    Day Phone:      
    Evening Phone:      
    Cell Phone:      
    Email Address:      
    Best Days/Times to Contact:      
    Preferred Contact Method:      



  1. Alternate Coordinator Name:      
    Day Phone:      
    Evening Phone:      
    Cell Phone:      
    Email Address:      
    Best Days/Times to Contact:      
    Preferred Contact Method:      



  1. Funding Organization to be named on Contract (please enter name exactly as it should read on the contract):      
    Person’s name responsible for processing contract and invoices:      
    Day Phone:      
    Fax Number
    :      
    Email Address:      
    Best Days/Times to Contact:      
    Preferred Contact Method:      



  1. Address to mail contract and invoices:
    Street:      
    City: :       State:       Zip/Postal Code:      




  2. Special notes about contract and/or invoice:      




TRAVEL LOGISTICS
Challenge Day will make the necessary reservations for air travel, hotel, and car rental.
AIRLINE INFORMATION

1st Closest Major Airport (please enter the airport’s full name):      

1st Closest City:      

Airport code:      

Travel time from the airport to the Challenge Day location:      

Distance from the airport to the Challenge Day location:      
2nd Closest Major Airport (please enter the airport’s full name):      

2nd Closest City:      

Airport code:      

Travel distance from the airport to the Challenge Day location:      


Any Additional Airport/Airline Notes:      
HOTEL and CAR ARRANGEMENTS
Please note: Challenge Day will make all the arrangements. Please provide suggestions for Holiday Inn quality hotel near the workshop location.

Suggested Hotel Name:      

Address:      

City, State and Zip:      

Phone number:      



4/14/2016


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