Office Use Only
TEAM ASSESSMENT FORM 2012-2013
Please complete and return this form to:
Attn: Adventure Program, University Recreation, MSC 3901
James Madison University, Harrisonburg, VA 22807
E-mail: debrungb@jmu.edu Phone: 568-8713 FAX 568-8701
Scheduled & Confirmed:
________________
Program review
Coordinator
Client
Organization
Participant Paperwork:
Contact Person
E-mail
Position
Phone
________________
FAX
Facilitators:
________________
3 Prefered Program Dates
________________
Prefered Program Starting Times
________________
________________
Prefered Program Length
_________
________________
________________
Program Fees:
________________
Student Groups:
Half day 2-4 hours -$10 per person
Full Day 5-8 hours - $18 per person
Non- Profit:
Half day 2-4 hours - $20 per person
Full day 5-8 hours - $30 per person
JMU Faculty/Staff:
Half day 2-4 hours -$15 per person
Full day 5-8 hours - $25 per person
Corporate:
Half day 2-4 hours - $30 per person
Full day 5-8 hours - $40 per person
For JMU Departments Only: Information for ATV (Account Transfer for Payment)
Organization Code:
Account Code:
Process
1) Complete and return the assessment form – including group information
2) Agreeement and confirmation regarding date and time
3) Participants will be required to sign waivers – if you would like a copy of this
ahead of time we will be happy to send it to you
4) One week from trip you will receive a reminder/confirmation about numbers of
participants, location of program, and what participants should wear and
bring
5) Following the program you will receive a program evaluation and a request for
payment.
6) You may contact the adventure office for any questions, conflicts, or changes
in scheulde
Group Information
Please complete the following to help us design your program
How many participants?
Approximate age range?
If applicable, how many adult chaperones?
Are there any special needs or requirements necessary for participation?
Please explain
Please check the group development stage or stages that best represents your group.
Forming…members’ are striving to become oriented towards each other.
Storming…members’ are confronting their various differences.
Norming…members’ have developed consensus regarding group norms and values.
Performing…members’ work as a unit to achieve group goals.
Adjourning…memebrs’ task is complete or has ended.
What are the recognized goals for this experience
Group bonding and getting to know each other
Planning and effective communication (resource utilization, engaged communication, defining a goal, inviting
imput, directing activity towards goal )
Creative thinking and Problem solving ( brainstorming, recognizing group members invidual strengths, adapting,
drawing on inviduals or groups previous knowledge or expreince and applying it to new situations,
Conflict Resolution ( listening, compromise, defining goals, trust, dealing with fear and uncertainty, entrusting
oneself to the physical/emotional care of others, willingness to become vulnerable, surrender of self for the group
cause
Other : please list
Explain any possible group issues or conflicts
Do you want these issues to be addressed?
Any questions or concerns?