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Today's Date:

Name:

Phone No:

Campus Address:

E-mail Address:

Best time to contact you:

Your title/organization/class:

Is this program fulfilling a requirement for your organization? If so, please explain:

Program Requirement:

Proposed location of program:

Proposed dates and times for your program:

Please choose dates that are at least 2 weeks in the future from today. Please list 3 different dates as options, NOT 3 different times on the same date.

1st choice Date AND Time:

2nd choice Date AND Time:

3rd choice Date AND Time:

No. of people expected to attend:

Choose the program topic/title you are requesting:

Disordered Eating (Pow! - ABIDE)

Get Up, Stand Up! Being a Courageous Bystander (S.O.S.)

Got Sugar? -- Healthy Sexuality (Pow! - SUGAR)

How to Be a Good Friend to a Person With an Eating Disorder (Pow! - ABIDE)

Human Continuum: Where Do You Stand? (S.O.S.)

Image...Imagine a Healthy One (Pow! - ABIDE)

Just Do It! Fitness and Nutrition Enhancement (Pow! - ABIDE)

Learn Massage! (Pow!) -- Specify in the box below "Hand Massage" or "Back Massage." NOTE: If you request back massage, you must reserve a private room (no windows to outer rooms, hallways, lounges). And your event should be for a group whose members know each other well, or make it known that participants should attend with a friend they trust.

Stress Management (Pow!)

"Wanna Smush?" -- How Do You Ask for Consent? (S.O.S.)

Why Doesn't She Just Leave? -- Intimate Partner Violence (S.O.S.)

If your programming needs aren't met by the list above, check our Upcoming Events list at the bottom of every page throughout our website for upcoming programs being offered by our office that might meet your group's needs. OR:

Request to meet to discuss a unique program not listed on this form. Please provide your availability below.

Tell us more about the program topic you are seeking and the specific needs of the group who will attend this program:

Publicity is the responsibility of the requestor, unless the program is co-sponsored by many organizations for a campus-wide event. If you are requesting a program for a large group of people, make sure to reserve a room that will accommodate a large group and still allow room to move around and interact; most of our programs are interactive in nature.