Climbing Wall Request Form

Contact Person

Mailing Address

City, State, Zip

Phone Number

Email Address

Event Type

Birthday Party

Social Gathering

Team Development

Private Lesson/Group Lesson

Other…

Affiliation with the University of Iowa

UI Student, Group, or Organization

UI Faculty, Staff, or Department

Not affiliated with the University of Iowa

Organization or Group Name

Reason for event

Group Size

1-10

11-15

16-20

21-25

Other…

Number of Individuals Participating in Private Lesson

How many climbers are 18 years or older?

Preferred Event Date and Time

Second Preferred Event Date and Time

Preferred Payment Option

Blue Req

Cash

Check

Credit Card

MFK

Anything else we should know about your request?