intake-form | Nau Choice Wellness

PROJECT 85™

Organization Program Intake Form

A FREE wellness initiative of Nau Choice Wellness™

Thank you for your interest in bringing Project 85™ to your organization. This form helps Nau Choice Wellness™ understand your organization, the population you serve, your program goals, and any facility or participation considerations before programming begins.

ORGANIZATION INFORMATION

Organization Name:

PROJECT 85™ INITIATIVE SELECTION

Which initiative is your organization interested in?

Youth Resilience Initiative

Women Empowerment Initiative

Both Initiatives

Organization Address:

City:

State:

Zip:

Organization Website:

PRIMARY CONTACT

First name

Last name

Title / Position:

Email

Phone

Preferred Method of Contact:

Phone

Email

Text

Other

PROGRAM INFORMATION

Program Name / Department:

Approximate Number of Participants:

Participant Age Range

Typical Group Size:

Gender / Population Served, if relevant to program planning:

Preferred Program Start Date:

Preferred Days / Times:

PROGRAM GOALS

What would your organization like Project 85™ to support?

What are the primary needs or goals you would like Project 85™ to address?

PARTICIPANT CONSIDERATIONS

Please share any information that may help Nau Choice Wellness™ prepare an appropriate group experience.

Accessibility Considerations

Physical Participation Considerations

Environmental or Sensory Considerations

Behavioral or Program Considerations

Other Relevant Considerations

FACILITY INFORMATION

Program Location:

Room / Space Available:

Approximate Room Capacity:

Is there enough space for participants to move comfortably?

Yes

No

Unsure

Are chairs available if needed?

Yes

No

Are mats available?

Yes

No

Nau Choice Wellness will provide them

Other

Equipment Restrictions

Please list any equipment that may not be permitted at the facility.

FACILITY & SECURITY REQUIREMENTS

Check-In / Entry Procedures

Security Requirements

Visitor Requirements

Identification / Clearance Requirements

Staff Presence Requirements

Cell Phone / Electronic Device Policies

Other Facility Policies

PARTICIPANT SUPERVISION

Who will be responsible for general supervision of youth participants during the program?

Organization Staff

School Staff

Facility Staff

Other

Number of organization staff expected to be present:

Staff Contact During Program:

Phone / Extension:

Unless otherwise agreed in writing, the participating organization remains responsible for general participant supervision, facility safety, security, and facility-specific emergency procedures.

EMERGENCY INFORMATION

Organization Emergency Contact:

Emergency Phone:

Emergency Procedures / Protocol:

Nearest designated medical/emergency response location, if applicable:

Additional emergency instructions:

PARENT / GUARDIAN CONSENT

Does your organization require parent or legal guardian consent for youth participation?

Yes

No

Organization will determine based on applicable requirements

If yes, who will be responsible for obtaining and maintaining the required consent?

Participating Organization

Nau Choice Wellness™

Shared Responsibility

Other

Additional requirements:

PHOTOGRAPHY / VIDEO / MEDIA

Does your organization permit photography or video during Project 85™ programming?

Yes

No

Organization approval required

Facility-specific media requirements:

Any photography, video, or other media involving youth participants must follow the requirements of the participating organization and any applicable parent/guardian permissions.

PROGRAM SAFETY & PARTICIPATION

Please identify any organization-specific safety policies that Nau Choice Wellness™ must follow.

Are there activities or practices that are restricted or prohibited at your facility?

Are there topics or practices that should be avoided with this participant population?

ORGANIZATION EXPECTATIONS

What would make Project 85™ successful for your organization?

Is there anything else you would like Nau Choice Wellness™ to know before programming begins?

ACKNOWLEDGMENT

By submitting this form, the participating organization acknowledges that the information provided is intended to help Nau Choice Wellness™ prepare and deliver Project 85™ programming appropriately within the organization's setting.

The organization understands that Project 85™ offers free programming for individual participants through its Youth Resilience Initiative and Women Empowerment Initiative. Any separate organizational service, partnership, compensation, scheduling, or contractual terms will be established through the applicable organizational agreement.

This intake form does not by itself create a contractual relationship or guarantee program availability. A separate agreement may be required before services begin.

ORGANIZATION REPRESENTATIVE

Name:

Title / Position:

Date:

Signature

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