Health Promotion Programming-Request Form
The following form is a request only. Please provide at least a two week notice of the event, to allow use adequate time to schedule and prepare for your successful wellness program. Health Promotion will confirm all details of request via email.
First Name:
Your answer
Last Name:
Your answer
Contact phone number:
Your answer
University email address:
Your answer
Campus department, student organization or residence hall:
Your answer
Wellness topic (Please, be specific):
Your answer
Location of event:
Your answer
Date of event (1st choice)
MM
/
DD
/
YYYY
Date of event (2nd choice)
MM
/
DD
/
YYYY
Date of event (3rd choice)
MM
/
DD
/
YYYY
Time of event (1st choice)
Time
:
Time of event (2nd choice)
Time
:
How many students will be present:
Your answer
Remember, this is not confirmation of your scheduled program. A Health Promotion representative will contact you to confirm your program or presentation.
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