Section 1 of 3
Knox College Counseling Services Outreach Request Form
To request a presentation by one of our counselors or Peer Educators, please complete this form no less than two weeks prior to the event. After reviewing the information, we will be in touch with your contact person to discuss the request. If you have any questions, please contact us at 309-341-7492.
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Event Name
Event Name
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Event Date
Event Date
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Event Start Time
Event Start Time
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Event End Time
Event End Time
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Event Location (Address, Building, and Room #)
Event Location (Address, Building, and Room #)
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Organization/Department Holding the Event
Organization/Department Holding the Event
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Section 2 of 3
Event Content
Help us understand what you are looking for in the event.
Type of Event
Type of Event
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Presentation
Open Discussion
Workshop
Education
Other…
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Topics of Discussion
Topics of Discussion
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Audience
Audience
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Current Students (All Classes)
Freshman
Sophomores
Juniors
Seniors
Parents/Family
Professionals/Educators
Future Students
Other…
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Anticipated Number of Attendees
Anticipated Number of Attendees
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Other Considerations or Requests
Other Considerations or Requests
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Section 3 of 3
Contact Information
Provide a contact person for this event. We will contact this person to discuss our ability to fulfill the request, ask any further questions, and confirm event details.
Name
Name
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Organization/Department
Organization/Department
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Email
Email
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Phone Number
Phone Number
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