Presentation/Workshop Request Form
Your Name:
Telephone:
E-Mail:
Status:
Program Information
Preferred Date(s) and Times:
*** Make certain to give at least two weeks to plan and organize the logistics involved with scheduling a program.***
1. Please describe your program topic and the type of presentation which you are requesting.
2. Is there a particular Counseling & Consultation Center staff member whom you would like to facilitate this program?
<Blank> Judith Cepeda Lee Land Will Pannabecker Sarah Porter Selia Servin-Lopez Peer Health Educator Other Staff None of the Above
3. Do you need assistance with the promotion or advertisement of this program? If yes, please explain.
Please provide any additional information which might be helpful.
