Professional Staff Presentation Request Form

Please refer to peer education programs FIRST for presentations.  Professional staff are available upon request if you do not see the topic area you'd like covered in our peer education programs.  Professional staff can tailor presentations to meet specific needs.  Please give 2 weeks notice when requesting a presentation from professional staff.

Contact Information

Last Name: *

First Name: *

Preferred Phone: *

Alternate Phone:

Email: *

How did you hear about us?: *

Other/Special Instructions:

Program Information

Topic area requested: *

UHC 101 General Health Center Presentation

Alcohol & Other Drug Responsibility

General Wellness

Meditation

Nutrition

Services at the Health Center

Sexual Assault Response and Prevention

Sexual Health

Stress Management

Suicide Prevention

Tobacco Cessation

1st choice date: *

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Year201320142015

1st choice time: *

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2nd choice date: *

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year201320142015

2nd choice time: *

hour123456789101112

:

minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

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pm

Location of Program Building: *

Room: *

What best describes the technology in in your classroom?: *

My classroom has built in technology (computer, projector).

I will arrange for technology to be brought to the classroom.

I do not have access to technology in my classroom.

Group information

Name of group, class, or residence hall: *

Audience size (at least 10): *

Short description of audience (Male /female; year, etc.): *

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