Wellness Program Request Form
Email address *
Name *
Your answer
Phone Number *
Your answer
UMaine affiliation *
If you're an RA, please tell us your building.
Your answer
Program Requested *
For example: Alcohol and Other Drugs, Bystander Intervention, Sexual Health, Hazing Prevention, General Wellness, Stress & Time Management
Your answer
Date Preference 1 *
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Time
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Date Preference 2
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Time
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Date Preference 3
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Time
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Location of Program *
Your answer
Approximate Number of Participants
Please describe a few goals/learning outcomes you would like to achieve from this program *
Your answer
How did you hear about our programs? *
Your answer
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