Please note that you must have written approval in ADVANCE from your Program Director in order to host any GEAR UP event. Please complete the following form at least two weeks prior to your event. Your Program Director will contact you via email regarding approval or requests for further clarification.

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* 1. Name of Event:

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* 2. Which work plan requirement does this activity fulfill?

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* 3. School:

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* 4. Please provide a brief (50 words or less) description of your event:

The description you provide in the above field will be used to describe your event on the WV GEAR UP web site. It will also provide GEAR UP regional and central staff with a better understanding (and record) of your activity.

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* 5. Date and Time of Event:

Date
Time
Date
Time

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* 6. Event location details:

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* 7. Specific location details (e.g. building, room #, etc.):

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* 8. Event Coordinator:

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* 9. Site Coordinator (if different than Event Coordinator):

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* 10. Target Grade Level (check all that apply):

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* 11. Event Category:

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* 12. Target Audience (Check all that apply):

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* 13. Which of the four GEAR UP objectives does this activity meet? Check all that apply:

Note: If your event does not meet at least one of the goals listed above, then the event cannot be counted as a GEAR UP activity.

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* 14. Are any GEAR UP funds being used to pay for this event?

T