First Name:

Last Name:

Phone:

Email Address:

Are you requesting this program for a student organization or student leader group?

Yes
No

If yes, what is the name of the student organization or student leader group?

If no, what organization of department are you representing?

Are you requesting this program for a class?

Yes
No

If yes, what is the name of the class?

Program Information

Date Requested for Program (1st Choice):
Time Frame (1st Choice):

Date Requested for Program (2nd Choice):
Time Frame (2nd Choice):

Estimated Number of Participants:

Room Location:

Description of how the room is set up:

Program Facilitation

What areas are you most interested in having the L-TEAM address and facilitate on?

Ice Breakers and Energizers: Allows individuals, teams, and groups to get to know one another while participating in engaging and interactive activities

Team Building: Challenges teams and groups to work together towards creating a more successful outcome.

Communication: Allows for the practice of expressing thoughts and receiving information effectively.

Leadership Styles and Philosophy: Identifies personal leadership styles through assessments and introduces new ways to approach leadership through student development and leadership theory.

Goal Setting and Vision Development: Facilitates the process of envisioning future possibilities, discovering commitment and passion, and understanding the big picture.

Somatics and Embodied Leadership: Creates a space for students to approach leadership from a different perspective by using the body, mind, and spirit.

Other:

What is the mission, vision, or purpose of your organiztion or class?

Do any of the participants have physical limitations?

Yes
No

If yes, please explain:

Additional notes or comments: