Group Name:
Group Type:	SELECT ONE: Student Organization Student Staff Athletic Team Departmental Program Academic Class GW Program Staff External Program Unsure
Describe your group in one sentence:
How many people are in your group?
Person Requesting Session:
Contact Phone:
Contact Email:
Group Contact Day of Session: **must be different from above**
Day of Contact Phone:
Day of Contact Email:
Please choose the stage of development that best describes your group (please think carefully about this; your response is an important part of how we will structure the sequence of elements):
Forming - group members are being introduced Storming - differences in opinion are evident and tension often appears Norming - group members learn how to reach consensus and work around individual differences Performing - group is working towards specific goals and objectives together
What are your group's goals and objectives for this session? Refer to the examples below, then create your own set in the space provided.
For example: 1) Improve communication between members of our executive board; 2) Help us all to be more comfortable with one another's learning styles; 3) To challenge our staff to move beyond our current approaches to problems and tasks
First Choice Date (mm/dd/yy):
Start Time:
Finish Time:
Second Choice Date (mm/dd/yy): **must be later than First Choice Date**
Start Time:
Finish Time:
Notes (any physical limitations of participants, special requests or needs, questions for course staff):
For example: About 50% of our group has been to the SUMMIT before; or 1 member of our group is on crutches.
How many times has your group been on the course?	0 1 2 3 4 5 or more
Please choose any facilitators with whom you'd like to work:	none Isaac Agbeshie-Noye Erika Asgeirsson Jenn Baron Bridgette Behling Lauren Bishop Tyler Black Tamela Blalock Mallory Boyd Kelly Carder Hannah Carlton Thomas Cavett Maria DeBonis John Estrada Courtney Fain Tim Gowa Laura Harrington Erich Heckel Shelby Hickman Katharine Hubbard Aubre Jones Hannah Kast Molly Kastendieck Cameron Klementik Danielle Kochavi Joseph Laliberte Chloe Lew Tom London Kanika Metre Tim Miller Chris Murphy Mario Peraza Ally Pregulman Charlotte Purcell Ashley Randall Molly Ray Rachael Reichen Naomi Rennard Katie Rosenbusch Elan Schnitzer Heather Schoff Hope Singleton Rebecca Slotkin Joshua Smolevitz Robert Snyder Collin Swan Lilian Ting Ashley Venneman Cora Walker Cheryl Walton Cate Waugh Erica Wertheim
Other Facilitator(s):	none Isaac Agbeshie-Noye Erika Asgeirsson Jenn Baron Bridgette Behling Lauren Bishop Tyler Black Tamela Blalock Mallory Boyd Kelly Carder Hannah Carlton Thomas Cavett Maria DeBonis John Estrada Courtney Fain Tim Gowa Laura Harrington Erich Heckel Shelby Hickman Katharine Hubbard Aubre Jones Hannah Kast Molly Kastendieck Cameron Klementik Danielle Kochavi Joseph Laliberte Chloe Lew Tom London Kanika Metre Tim Miller Chris Murphy Mario Peraza Ally Pregulman Charlotte Purcell Ashley Randall Molly Ray Rachael Reichen Naomi Rennard Katie Rosenbusch Elan Schnitzer Heather Schoff Hope Singleton Rebecca Slotkin Joshua Smolevitz Robert Snyder Collin Swan Lilian Ting Ashley Venneman Cora Walker Cheryl Walton Cate Waugh Erica Wertheim
Other Facilitator(s):	none Isaac Agbeshie-Noye Erika Asgeirsson Jenn Baron Bridgette Behling Lauren Bishop Tyler Black Tamela Blalock Mallory Boyd Kelly Carder Hannah Carlton Thomas Cavett Maria DeBonis John Estrada Courtney Fain Tim Gowa Laura Harrington Erich Heckel Shelby Hickman Katharine Hubbard Aubre Jones Hannah Kast Molly Kastendieck Cameron Klementik Danielle Kochavi Joseph Laliberte Chloe Lew Tom London Kanika Metre Tim Miller Chris Murphy Mario Peraza Ally Pregulman Charlotte Purcell Ashley Randall Molly Ray Rachael Reichen Naomi Rennard Katie Rosenbusch Elan Schnitzer Heather Schoff Hope Singleton Rebecca Slotkin Joshua Smolevitz Robert Snyder Collin Swan Lilian Ting Ashley Venneman Cora Walker Cheryl Walton Cate Waugh Erica Wertheim