Outdoor Group Challenge Request Form

Group Name:

Contact Info

First Name:

Middle Initial:

Last Name:

Email Address:

Phone:

Address:

Address 2:

City:

State:

Zip Code:

Event Info

Event Type:

Desired Date:

Arrival Time:

Departure Time:

# of Participants:

Overall age of participants:

Special arrangements or any physical limitations/concerns?

Goals and any background information:

Diakon does not discriminate in admissions, the provision of services, or referrals of clients on the basis of race, color, creed, religion, sex,
national origin, sexual orientation, age, marital status, veteran status, disability or any other classes protected by law.