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Today's Date:

Name:

Phone No:

Campus Address:

E-mail Address:

Best time to contact you:

Your title/organization/class:

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 just 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".]

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.)

Design Your Own - tell us what you want

Please tell us more about the specific program topic you would like us to offer 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.