Girls Inc. of Southwestern CT

Outreach Program Request Form

Program Requested: * Organization/School: * Address 1: * Address 2: City/Town: * State * Zip Code: * Contact Person * Phone: * Email: * Day of the Week Requested: * Alternative Day of the Week: * Time Requested: *

Start Date Requested: * End Date Requested: * Length of Program (Number of Weeks): * Days per Week: * Number of Participants: * Grade Level: * Program Requested to be Conducted on Site: * Program Requested to be Conducted off Site: * Questions/comments:

* - required fields

Girls Inc of southwestern connecticut

Outreach Program Request Form