Contact Person:

Mailing Address:

Daytime Phone:

Evening Phone:

Email Address:

Age Range of Participants:

# of Males:            # of Females:

Briefly describe the relationship of the participants in the group.  What type of organization? (Club, Classmates, Sports Team, Staff, etc.) How long have they known each other?  How often do they interact with each other?

Please describe the group’s previous participation in experiential education programs. (other ropes courses, team building, backpacking, camps, etc.)

Participation in this program is: Mandantory       Voluntary

What special needs are present throughout or within the group? (at risk, physical disabilities, dietary concerns, language barriers, ADHD, etc.)

Please rank the level of emphasis to be placed on the following challenge areas:

(1 = low and 5 = high)

Physical Challenge:  1     2     3     4     5

Emotional Challenge:  1     2     3     4     5

Intellectual Challenge:   1     2     3     4     5

What are the top three issues that you would like for you group to focus on during this program?

1.

2.

3.

Please rank each of these areas as they apply to your group as a whole:

(1 = Poor and 5 = Excellent)

Ability to Focus 1     2     3     4     5

Communication 1     2     3     4     5

Listening  1     2     3     4     5

Patience   1     2     3     4     5

Physical Fitness   1     2     3     4     5

Problem Solving   1     2     3     4     5

Punctuality   1     2     3     4     5

Respect for Others   1     2     3     4     5

Trust with the Group   1     2     3     4     5

What do you consider the group’s most positive assets?