Agency Application
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Agency/School Name
Address
Please remember to include zip code
Program Director/Principal
Name, phone and email
1st Contact Person
Name, position, phone and email
2nd Contact Person
Name, position, phone and email
Describe your program. What is your mission?
How many people will be involved in ICO from your group?
Gender of group
Please check all that apply
Clear selection
Race/Ethnic groups
Age range of group
Do any of the participants have special needs?
Clear selection
If yes, please explain
Would we be able to meet with all participants within one week of the planned trip?
Clear selection
If yes, where would the meeting be?
Please include an address
When is this space available?
Check all that apply
When is your group available for trips?
Clear selection
Which of these activities have the participants had the opportunity to do?
Check all that apply
May we take participants out of the county?
Clear selection
How much parental participation can we expect?
Beneficial, but not required
Clear selection
Would the agency be able to provide any of the following
Appreciated, but not required
Will you be willing to work with us for at least one year?
Clear selection
What would be the greatest benefit to your young people that ICO would be able to provide?
Additional comments
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