Washington State University
University Recreation & Wellbeing
Program Intake Form
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Exercise.wsu.edu
UREC Program Intake
Contact Information
First Name
Last Name
Email
Phone
Alternate Phone
Group Information
Group Name
Legal Billing Address
Zip / WSU Mail Code
ID
WA
We are:
WSU Student Group
WSU Staff or WSU Other
WSU Academic Group
Other Group Type
Please tell us the number of people in your group:
Please describe your group :
Type of Program
(check all that apply):
Challenge
Competitive Sports
Eco-Adventrure
First Aid/CPR/AED
Group Fitness Classes
Health & Fitness Workshop
Health/Fitness Assessments & Small Group Training
Leadership
Massage Services
Outdoor Adventure
Outdoor Trip
Wellbeing Workshop
Date/Time Information
Single Day
Multiple Day
Undetermined
Date:
Time:
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
A.M
P.M
-
1
2
3
4
5
6
7
8
9
10
11
12
:
00
15
30
45
A.M
P.M
Facilities:
On Campus
Off Campus
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.
