University Recreation

Program Intake Form


Contact Information

First Name Last Name
Phone Alternate Phone

Group Information

Group Name
Legal Billing Address
Zip / WSU Mail Code

We are: 

Please tell us the number of people in your group:

Please describe your group : 

Type of Program (check all that apply):

Date/Time Information
:  - :  
 Please describe your goals for the program (leave blank if you are unsure). 
Please feel free to include any other information you feel may be useful.

Challenge & Leadership Programs, PO Box 641830, Washington State University, SRC 142 * Pullman, WA 99164-1830, 509-335-4444, Contact Us