Book Up and Over

MY INFORMATION

Name: (*)

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Day Phone: (*)

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Email: (*)

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My Role / Relationship to the School: (*)

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Best Way to Contact: (*)

PhoneEmail

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School / Organization Information

School / Organization Name: (*)

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Street Address: (*)

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City: (*)

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State: (*)

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Zip: (*)

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Dates Requested

Our Performance Presentation is FREE, however, schools or organizations that require travel by air or are more than a 30 minute drive from Portland, OR will be required to cover travel expenses. Travel expenses will be billed on a per school, per day basis.

If you are booking a Workshop, you will pay our set workshop fee for the option you choose, plus travel expenses. Please see our Price Sheet Thank you!

What Are You Requesting?: (*)

Up and Over Presentation/Assembly
Achieve Against the Odds (youth)
Evolution of a Bully (youth/adults)
Educator Workshop
Parent Workshop
Mentoring

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Dates:

Choice 1:

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Choice 2:

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Choice 3:

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COORDINATOR INFORMATION

The Coordinator is the person who works closest with UP and OVER in coordinating all the details of the day(s). The coordinator must be part of the Host School staff, and must be a school administrator, a teacher or a counselor working closely with the administration.

We require that a counselor or licensed mental health professional, employed by the school, be available to ensure follow-up services to students if needed.

I am the coordinator (fill in below if you will NOT be the coordinator)

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Coordinator Name:

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Day Phone: (*)

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Email: (*)

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Best Way to Contact: (*)

PhoneEmail

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School Principal

Principal Name:

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Email: (*)

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ADDITIONAL SCHOOL/ORGANIZATION INFORMATION

Please fill out this section as thoroughly as possible. Your information helps us create the best program possible for your school or your organization.

Type of school
(High school, middle school, private, alternative, youth services, charter, community etc) (*)

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Total Number of Students at Your School (*)

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Anything you would like to tell us about your school?:

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ISSUES AND GOALS

This is where you describe to us the issues you see and the goals you hope for. (If you are filling this out for an organization, please read "organization" instead of "school" in the following questions.) Please be as complete as possible. Thanks! Please describe the social climate at the school. How do people interact with each other? How do you see your school? Have there been any recent tragic or traumatic events? What are the challenges at the school? What are the opportunities?

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Please don’t hesitate to contact us with any questions!

Up and Over
contact@upandovertour.com
www.upandover.net
971-270-0637

Please enter this code for verification (*)

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	MY INFORMATION
Name: (*)	Invalid Input
Day Phone: (*)	Invalid Input
Email: (*)	Invalid Input
My Role / Relationship to the School: (*)	Invalid Input
Best Way to Contact: (*)	PhoneEmail Invalid Input
	School / Organization Information
School / Organization Name: (*)	Invalid Input
Street Address: (*)	Invalid Input
City: (*)	Invalid Input
State: (*)	Invalid Input
Zip: (*)	Invalid Input
	Dates Requested Our Performance Presentation is FREE, however, schools or organizations that require travel by air or are more than a 30 minute drive from Portland, OR will be required to cover travel expenses. Travel expenses will be billed on a per school, per day basis. If you are booking a Workshop, you will pay our set workshop fee for the option you choose, plus travel expenses. Please see our Price Sheet Thank you!
What Are You Requesting?: (*)	Up and Over Presentation/Assembly Achieve Against the Odds (youth) Evolution of a Bully (youth/adults) Educator Workshop Parent Workshop Mentoring Invalid Input
	Dates:
Choice 1:	Invalid Input
Choice 2:	Invalid Input
Choice 3:	Invalid Input
	COORDINATOR INFORMATION The Coordinator is the person who works closest with UP and OVER in coordinating all the details of the day(s). The coordinator must be part of the Host School staff, and must be a school administrator, a teacher or a counselor working closely with the administration. We require that a counselor or licensed mental health professional, employed by the school, be available to ensure follow-up services to students if needed.
	I am the coordinator (fill in below if you will NOT be the coordinator) Invalid Input
Coordinator Name:	Invalid Input
Day Phone: (*)	Invalid Input
Email: (*)	Invalid Input
Best Way to Contact: (*)	PhoneEmail Invalid Input
	School Principal
Principal Name:	Invalid Input
Email: (*)	Invalid Input
	ADDITIONAL SCHOOL/ORGANIZATION INFORMATION Please fill out this section as thoroughly as possible. Your information helps us create the best program possible for your school or your organization.
Type of school (High school, middle school, private, alternative, youth services, charter, community etc) (*)	Invalid Input
Total Number of Students at Your School (*)	Invalid Input
Anything you would like to tell us about your school?:	Invalid Input
	ISSUES AND GOALS This is where you describe to us the issues you see and the goals you hope for. (If you are filling this out for an organization, please read "organization" instead of "school" in the following questions.) Please be as complete as possible. Thanks! Please describe the social climate at the school. How do people interact with each other? How do you see your school? Have there been any recent tragic or traumatic events? What are the challenges at the school? What are the opportunities?
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	Please don’t hesitate to contact us with any questions! Up and Over contact@upandovertour.com www.upandover.net 971-270-0637
Please enter this code for verification (*)	Invalid Input