Name

Date

Number of Programs You Have Already Preformed To Date

Title of Program

Classification of Program:

Short Description of the Program

Program Objectives and Purpose

Did Your Residents Suggest This Program? _ no yes

Did You Discuss This Program With Over Five Residents: _ no yes

Resources You Will Need (including speakers):

Proposed Date(s) for this Program:

Time and Place of Program:

Program Funding:

Amount Needed:

RA Will:

Pay with own funds
Need money in advance
Need no funding

This proposal must be submitted to your Area Coordinator at least one week before the proposed date.
No programs preformed without the approval of your AC will count toward your programming requirements.