CSU Health Insurance Education Project: Presentation Request Form for Campus Events
The following form is for San Jose State University student leaders and staff to request a Certified Covered California Educator provide a 5, 10, or 15 minute educational presentation to students (and their families, if applicable) on how students and their families can access health care coverage under the Patient Protection & Affordable Care Act.  

Presentation requests can be scheduled anytime during the Fall 2013 and Spring 2014 semesters. Presentations are only available to SJSU students.  We will come to your meetings, orientations, campus events, etc.!

Please provide at least three days advance notice for requests.  We will try our best to meet your scheduling needs.  Thank you! Questions? Contact the CSU Health Insurance Education Project SJSU Campus Coordinators & Certified Covered California Educators: sjsuhiep@gmail.com.
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Contact Information
Requestor Name *
First & Last
I am a: *
Required
Email *
Phone number
408-555-5555
Would you like to be added to our email listserv for important updates on the CSU Health Insurance Education Project at SJSU? *
(Emails will be sent occasionally.) Check one.
Required
Campus Event Presentation Request #1
Name of event for which you are requesting a presentation *
e.g., MOSAIC Open Mic
Number of SJSU students *
Number of SJSU students' family members
Leave blank if not applicable to your event.
Date of event *
MM
/
DD
/
YYYY
Time you are requesting the presentation START *
Time
:
How long would you like the presentation to be? *
(note: 10 and 15 minute presentations are recommended to allow time for student questions)
Location of event *
e.g., SU Ballroom
Please tell us about the technology you will have available. *
Check all that apply.
Required
Comments/Questions/Special Considerations/Accommodations?
Please tell us about any comments, questions, special considerations, and/or accommodations you or your students might have/need.
A second request can be submitted on the following page.  To submit the form without requesting an additional presentation, scroll to the bottom of the following page (page 2), and click "submit."
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