University Recreation

Program Intake Form

 

Contact Information

First Name Last Name
   
Email
     
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
Date:    
         
Time:
:  - :  
 
Facilities: 
 
 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