Organization or Group Name * Affiliation with the University of Iowa * UI Student Group/Organization UI Faculty, Staff, or Department Not affiliated with the University of Iowa Contact person * Mailing address * City, State, Zip * Phone * Email * Program Preference * Half Day - low elements only (3-4 hours) Half Day - low and high elements (4 hours) Full Day - low and high elements (6-8 hours) Preferred Event Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021 We will try everything we can to ensure you get your preferred date, but please select two other choices in case we need to find another time. Second Choice Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021 Third choice Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20172018201920202021 Preferred Start Time * Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Second Choice Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Third Choice Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Anticipated number of participants (12 participant minimum charge) * Participants with special needs Reason for event * Please choose three areas you would like to focus on * Communication Respect Confidence Exploring Diversity Conflict Resolution Play/fun Teamwork Problem-solving Trust Billing Person (if different from above) Billing Address (if different from above) Billing Email (if different from above) Billing Phone (if different from above)