Program Request Form
Thank you for your interest in our programs! We are now scheduling for the Spring of 2008 and the Summer of 2008 and for the 2008-09 school year.
Please make sure you've completed the required steps outlined on How to Bring a Challenge Day before submitting this form to us.
After we receive your completed form, we will contact you to confirm your requested dates and begin the contract and coordination/coaching processes. Again, thank you! You are the change!
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My Information
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My Name *
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Day Phone *
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Evening Phone
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Cell Phone
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Fax
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E-Mail *
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Best days/times/method to contact me
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My Role/Relationship to School or Organization *
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School Information
Please tell us about the school or organization whose students will attend Challenge Day. This school or organization will be listed as the "Host Organization" on your contract.
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School/Organization Name *
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Please enter name exactly as it should read on the contract.
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Address 1 *
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Address 2
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City *
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State *
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Zip *
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Country *
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Dates Requested
Schools or organizations that require travel by air or are more than a 1-hour drive from Concord, CA must book a minimum of three or maximum of four consecutive days shared by no more than two schools per trip. Please see our price sheet.
Thank you!
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Number of Days Requested *
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School Year
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We are now scheduling for the Spring of 2008 and the Summer of 2008 and for the 2008-09 school year.
Requested Program Day Date(s) - enter a starting date in each field for 1st, 2nd, and 3rd choices (Hint: Click on 'calendar'. Dates must be in the format mm/dd/yyyy)
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Choice 1 *
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Choice 2 *
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Choice 3 *
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Funder Organization (Contract & Invoices)
The Funder Organization is the organization that will be paying for the program days. This organization will be listed as the Client on the contract.
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Most of the time the Funder Organization is the same as the Host School. The Funder may be different than the Host if a school district is paying for a school, or if an organization is donating a day to a school.
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Funder is SAME from the Host Org
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Funder Organization Name *
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Please enter name exactly as it should read on the contract.
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I am the Funder representative.
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I'm the funder representative.
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Funder Representative Name *
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This is the name of the person authorized to sign the contract and process the invoices.
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Day Phone *
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Fax *
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E-Mail *
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Best days/times/method to contact them
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Contract & Invoice Address
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Contract & Invoice Address same as Host Org Address.
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Address 1 *
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This is the address where contracts and invoices will be mailed
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Address 2
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City *
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State *
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Zip *
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Country *
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Special Notes about contract and/or invoice
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Additional School/Organization Information
Please fill out this section as thoroughly as possible. Your information helps us create the best program possible for your community.
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Is your School/Organization public or private?
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Type of School/Organization
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Youth Services, Vocational, Parochial, Charter, Community, Court, etc.
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Total approximate number of students who attend your school
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Approximate racial/ethnic demographics
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Description of economic and social demographics
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Anything else you would like us to know about this school/organization
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Challenge Day History
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How many Challenge Days has your school/organization hosted in the past?
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(Please enter "0" if none.)
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How many Challenge Days has the Coordinator been involved in?
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(Please enter "0" if none.)
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Coordinator Information
The Coordinator is the person who works closest with Challenge Day in coordinating all the details of the day(s). The coordinator must be part of the Host School staff, and must be a school administrator, a teacher or a counselor working closely with the administration. The coordinator must also be able to be present in all of the program days for the duration of the program.
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I am the Coordinator!
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I'm the coordinator!
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Coordinator Name *
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Day Phone *
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Evening Phone
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Cell Phone
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E-Mail *
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Best days/times/method to contact the coordinator
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Be The Change Team Leader Information
This is the leader of the Be The Change Team.
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I am the Be The Change Team Leader!
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I'm the Be The Change Team Leader!
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Be The Change Team Leader Name *
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Day Phone *
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Evening Phone
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Cell Phone
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E-Mail *
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Best days/times/method to contact the team leader
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School Principal Information
This is the Principal of the host School/Org.
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I am the School Principal!
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I'm the School Principal!
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School Principal Name *
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Day Phone *
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E-Mail *
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Best days/times/method to contact the school principal
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