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

Contact Information

Last Name: *

Last Name

First Name: *

Preferred Phone: *

Alternate Phone:

Email: *

How did you hear about us?:

Other /Special Instructions:

Program Information

Program Requested: * - Select -Terp CHOICES (Terps Choosing Healthy Options in College Environment Safely)HEALTH works (Helping Establish A Lifestyle that Works)SARPP Educators (Sexual Assault Response and Prevention Program)SHARE (Sexual Health And Reproductive Education)

Topic Requested: * - Select -UHC 101 General Health Center PresentationWellness U (HEALTHWorks)The Mind Body Connection (HEALTHWorks)Eating Your Way through College (HEALTHWorks)Establishing a Healthy Ideal: Body Image & Eating Disorders (HEALTHWorks)Sexual Assault Overview (SARPP)Relationship Violence (SARPP)Stalking (SARPP)Bystander Intervention Skills (SARPP)When is Sex Rape Video and Discussion workshop (SARPP)The Ins & Outs of Safer Sex (SHARE)Safer Sex Workshop (SHARE)Wasted Knowledge: A Conversation about Alcohol & Drugs in College (CHOICES)

1st Choice Date: *

MonthJanFebMarAprMayJunJulAugSepOctNovDec

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Year20102011201220132014

1st Choice Time: *

hour123456789101112

:

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am

pm

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

2nd Choice Date: *

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year201020112012

2nd Choice Time: *

hour123456789101112

:

minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859

am

pm

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?: * - Select -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.

Please choose one

Group Information

Name of Group, Class or Residence Hall:: *

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

Audience Size (At least 10): *

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