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Challenge Day Program Request Form



We are currently scheduling for the 2010-11 and 2011-12 school years

What You Can Expect From Challenge Day

Thank you for your interest in our programs!

Please review the form before filling out to make sure you have all of the information necessary and allow enough time to fill out fully.

When you hit SUBMIT, you will get a webpage here with a Receipt Number. Be sure to print that page for your records and save the Receipt Number. If you do not receive a Receipt Number, please call our office at 925.957.0234 and ask for our IT Manager.

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 being the change!

My Information
My Name *
Day Phone *
Evening Phone
Cell Phone
Fax
E-Mail *
Best days/times/method to contact me
My Role/Relationship to School or Organization *
Name

School or organization whose students will attend Challenge Day. This school or organization will be listed as the "Host Organization" on your contract.

If you are working/piggybacking with another school in you area to meet our 3 day minimum / 4 day maximum booking policy, please encourage them to sumbmit their individual Program Request Form.

School/Organization Name *
Please enter name exactly as it should read on the contract.
Address 1 *
Address 2
City *
State *
Zip/Postal Code *
Country *
Name


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 consecutive days shared by no more than two schools per trip. Please see our price sheet. Travel expenses will be billed on a per school, per day basis. If you do not have the required 3 day minimum / 4 day maximum, we still encourage you to submit this PR Form so we can contact you and see if it is possible to book your program with a school in your area.
Download Price Sheet (PDF)

Challenge Day Price Sheet



Program Cost

The Challenge Day youth program is $3,200 per day, plus travel expenses.

Minimum Number of Days

Schools or organizations that are more than a 1-hour drive from Concord, California, or that require air travel, must book a minimum of three (3) consecutive days* shared by no more than two schools per trip.

Travel expenses are billed on a per school, per day basis.

*If you do not have the required 3 day minimum, we still encourage you to submit a Program Request Form (PR Form) so we can contact you and see if it is possible to book your program with a school in your area.

Included in Program Cost

  • Pre-program coaching
  • One six-hour program for a maximum of 100 youth and a minimum of 25 adults
  • Two trained Program Leaders
  • Unlimited phone consultation
  • Banners to promote the teachings of Challenge Day
  • Post-program follow-up
Travel Expense Estimates - Local to Concord, CA

Estimates of additional costs for schools or organizations that are more than a one hour drive from Concord, CA

Lodging Two hotel rooms (equal to or above the quality of a Holiday Inn) for every night prior to your Challenge Days

We encourage you to see if hotels in your area will donate or discount. We need two hotel rooms per night, Holiday Inn quality or better.

$300 per day


Transportation -

Mileage or rental car (van or SUV required)

$100 – $150 per day
Travel Expense Estimates - Air Travel

Estimates of additional costs for schools or organizations that require air travel or overnight car travel.

Air Travel

Two round-trip airline tickets from Oakland or San Francisco, CA

$600-$2500
Baggage Fees

Due to airlines having recently increased their fees.

$200-$600
Lodging

Two hotel rooms (equal to or above the quality of a Holiday Inn) for every night prior to your Challenge Days Schools have had success with local hotels donating rooms for these events.

We encourage you to see if hotels in your area will donate or discount. We need two hotel rooms per night, Holiday Inn quality or better.

$300 per day
Transportation

Car rental beginning the day prior to the workshop and for the duration of the workshop. SUV or Van is required to accommodate equipment.

$100 - $150 per day
Miscellaneous Supplies
$100 – $150


Total Additional costs for overnight car or air travel. (Estimate for 3 days)

$2,100 - $4,550

Deposit Breakdown

Option 1

Your Challenge Days can be paid in full as early as contracts are completed.

Option 2

Your Challenge Days can be paid in three installments: 90, 60, and 30 days before your event, using the following formula: $3,200 broken down as follows: $1200 for the 1st installment, $1,000 for the second, and $1,000 for the third for each program day.

Deposit Examples


Example A

You are having one Challenge Day on 1/30/2010

Balance for Program Days: $3,200

Schedule of Installments:

Installment
=========
1st
2nd
3rd
Due Date
=========
11/1/2009
12/1/2009
12/31/2009
Amount
=========
$1,200
$1,000
$1,000
Remaining
=========
$2,000
$1,000
$0

Example B:

You are having two Challenge Days, one on 1/30/2010 and one on 1/31/2010.

Balance for Program Days: $3200 x 2 = $6400

Schedule of Installments:

Installment
=========
1st
2nd
3rd
Due Date
=========
11/1/2009
12/1/2009
12/31/2009
Amount
=========
$2,400
$2,000
$2,000
Remaining
=========
$4,000
$2,000
$0
Thank you!

Number of Days Requested *
School Year

We are now scheduling for the 2011-12 school year.

Requested Program Day Date(s) - enter a starting date in each field for 1st, 2nd, and 3rd choices
(click the calendar icon to choose your dates)

Choice 1
Choice 2
Choice 3
Name

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 present at all of the program days for the duration of the program.

I'm the coordinator
Coordinator Name *
Day Phone *
Evening Phone
Cell Phone
E-Mail *
Best days/times/method to contact the coordinator
Name

We require that a counselor or licensed mental health professional, employed by the school, be present for the entire Challenge Day program. This person must also be available to ensure follow-up services if needed.

I'm the Counselor
Counselor Name *
Day Phone *
Evening Phone
Cell Phone
E-Mail *
Best days/times/method to contact the Counselor
Name

Principal of the host School/Org.

I'm the School Principal
School Principal Name *
Day Phone *
E-Mail *
Best days/times/method to contact the school principal
Name

The Funder Organization is the organization that will be paying for the program. This organization will be listed as the Client on the contract.

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.

Funder is SAME from the Host Org
Funder Organization Name *
Please enter name exactly as it should read on the contract.
I'm the funder representative.
Funder Representative Name *
This is the name of the person authorized to sign the contract and process the invoices.
Day Phone *
Fax *
E-Mail *
Best days/times/method to contact them
Contract & Invoice Address
Contract & Invoice Address same as Host Org Address.
Address 1 *
This is the address where contracts and invoices will be mailed
Address 2
City *
State *
Zip *
Country *
Special Notes about contract and/or invoice
Name

Please fill out this section as thoroughly as possible. Your information helps us create the best program possible for your school or your organization.

Is your School/Organization public or private?
Type of School/Organization
Youth Services, Vocational, Parochial, Charter, Community, Court, etc.
Total approximate number of students who attend your school
Approximate racial/ethnic demographics *
Description of economic and social demographics *
Anything else you would like us to know about this school/organization
(that is not covered in the Issues and Goals section below)
Name
How many Challenge Days has your school/organization hosted in the past?*
(Please enter "0" if none.)
How many Challenge Days has the Coordinator been involved in?*
(Please enter "0" if none.)
Name

This is where you describe to us the issues you see and the goals you hope for. (If you are filling this out for an organization, please read "organization" instead of "school" in the following questions.) Please be as complete as possible. Thanks!

Please describe the social climate at the school. How do people interact with each other? How do you see your school? Have there been any recent tragic or traumatic events? What are the challenges at the school? What are the opportunities?

School Issues *

Please describe the social climate at the community. What is the community like? How do the community issues feed into the school issues?

Community Issues *


What are the goals you have for Challenge Day? What is your vision? What are your hopes? What are your desired outcomes?

School Goals *


How does Challenge Day fit into your Be The Change school plan? And what activities are you planning to support keeping Challenge Day alive? Do you have other programs in place already that are addressing the school issues mentioned above? Do you have your Be The Change Team in place?

How Challenge Day Fits the Plan *
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