Name of School/Organization:
Address:
Borough:
Zip:
Contact:
Title:
Phone:
Email:

Please complete the following questionnaire.
All responses are confidential.


1.State your physical activity enrichment needs including the age/grade served:
  
2.Please check the programs you are interested in:
General Fitness:
Fitness Games
Youth Yoga
Youth Pilates
Aerobics
Strength and Conditioning
  
Martial Arts
Kickboxing
Capoeira
Karate
Other
  
Team Sports
Soccer
Basketball
Track
Volleyball
Other
  
Instructional Sports
Soccer
Basketball
Track
Volleyball
Other
  
Dance
Hip Hop
African
Creative Movement
Other
  
Physical Education
Check if you need an instructor to teach your physical education class
  
3.What type of space do you plan on using for your program?
  
4.When would you like for your program to begin?
  
5.How did you hear about us?







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