Name(s):

Today's Date:

Email Address:

Program Title:

Date & Time:

Location:

Who is your target audience?

How will your program benefit the residents?

Briefly describe the program/project and how it will address the identified needs/issues?

If you are working with another RA or group on this program/project, how will you each contribute to it?

How will the program be advertised and when will it begin?

Funding Needed:

Amount:

For:

How will you receive funding?

Reimbursment after program

Shopping with ADRL

Who of the following people need to receive this form?

Karolina Dreher

Rory Deegan

Andy Bright

Stacey Scherer