ACKNOWLEDGEMENTS
All presenting organizations or individuals must sign a contract, present a Certificate of Liability Insurance, and adhere to the Pennsylvania State System of Higher Education (PASSHE) Policy on Protection of Minors .
Group Name or Organization *
Name of Primary Contact
Name of Primary Contact *
First
Last
Title of Primary Contact *
Organization's Address
Organization's Address *
Street Address
Address Line 2
City
State / Province / Region
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Postal / Zip Code
Country
United States
Phone Number
Phone Number *
###
###
####
Email *
EIN Number for your organization. This will be required for the contract phase. *
Type of Course Requested *
Type of Course Requested
3 Hours LOW
3 Hours HIGH
3 Hour Indoor Group Initiatives
6 Hours High
6 Hours Combined LOW and HIGH
Program Date
Program Date *
MM
DD
YYYY
Rough Estimate based on staffing availability, we will contact you about a final date and time.
Program Time
Program Time *
HH
MM
AM PM AM/PM
Rough Estimate based on staffing availability, we will contact you about a final date and time.
If your preferred date is unavailable, are you flexible with scheduling? *
If your preferred date is unavailable, are you flexible with scheduling?
Yes
No
I/my organization is willing to sign a program contract. *
I/my organization is willing to sign a program contract.
Yes
No
I/my organization is able to provide a Certificate of Liability Insurance. *
I/my organization is able to provide a Certificate of Liability Insurance.
Yes
No
I/my organization agree to adhere to all guidelines related to the Protection of Minors who are directly or indirectly impacted by the event. *
I/my organization agree to adhere to all guidelines related to the Protection of Minors who are directly or indirectly impacted by the event.
Yes
No
Challenge Course Group *
Challenge Course Group
Millersville University Student Group
Millersville University Facility and Staff
K-12 Grade, School Group
Non-Profit Organization
Corporate or Business Group
Participant Age Ranges *
Participant Age Ranges
5th - 6th Grade
7th - 8th Grade
High School (14 - 18)
College (18 - 25)
Adult (25 and older)
Senior (65 and older)
How many PARTICIPANTS will you be bringing? *
How many non-participants will you be bringing? (ex. chaperones, other faculty, photographers, etc). *
Do the participants know each other? *
Do the participants know each other?
Yes, very well
Yes, a little bit/moderately
No
Has the organization and/or participants previously participated in a ropes or challenge course program? *
Has the organization and/or participants previously participated in a ropes or challenge course program?
Yes
No
Goals and objectives you'd like to focus on during your experience (choose 5 at most) *
Goals and objectives you'd like to focus on during your experience (choose 5 at most)
Cooperation
Trust and Respect
Communication
Leadership/Followship
Goal Setting
Commitment
Giving/Receiving Feedback
Giving/Receiving Support
Responsibility
Valuing Group Diversity
Camaraderie
Self-Awareness
Teamwork
Fun
22. How are you arriving to the Ropes/Challenge Course? *
22. How are you arriving to the Ropes/Challenge Course?
My organization is driving and we will meet you in the parking lot of Pucillo Gym
My organization is driving and we will walk down to the Ropes/Challenge Course by ourselves
My organization is walking over from a different on campus location and we will walk down to the Ropes/Challenge Course by ourselves
My organization is walking over from a different on campus location and we will meet you in the parking lot of Pucillo Gym
Will you group be taking a lunch/snack break DURING the program? *
Will you group be taking a lunch/snack break DURING the program?
No, we will eat before or after the program
Yes, 15 minutes
Yes, 30 minutes
Yes, 45 minutes
Do you anticipate needing any accommodations for your participants? (ex. wheelchair users or other mobility aids, children who work with 1:1 aids, service animals)
Do any participants have any relevant medical history we need to be aware of? (Example would be severe allergy to beestings, history of epilepsy, or recovering from a concussion)
Is there anything else our staff should know about your group to help us plan a successful experience?
Submission of this form does not guarantee program availability. A program coordinator will follow up to confirm details, pricing, and contract requirements.
Submission of this form does not guarantee program availability. A program coordinator will follow up to confirm details, pricing, and contract requirements.
I understand