Peer Education Presentation Request Form

All Fields with an asterisk (*) are Required
Please make your request at least 2 weeks prior to the date of the desired presentation. Please submit a request for 1 group per date and time.

Contact Information

Last Name: *

First Name: *

Preferred Phone: *

Alternate Phone:

Email: *

How did you hear about us?:

Other /Special Instructions:

Program Information

Program Requested: *

Topic Requested: *

1st Choice Date: *

1st Choice Time: *

Please note that we may not be able to accommodate requests after 9pm.

2nd Choice Date: *

2nd Choice Time: *

Please note that we may not be able to accommodate requests after 9pm.

Location of Program Building: *

Room: *

What best describes the technology in your classroom?: *

Please choose one

Group Information

Name of Group, Class or Residence Hall:: *

Audience Size (At least 10): *

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

Calendar

May

M	T	W	T	F	S	S
	1	2	3	4	5	6
7	8	9	10	11	12	13
14	15	16	17	18	19	20
21	22	23	24	25	26	27
28	29	30	31

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Peer Education Presentation Request Form

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May

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