2019-2020 Program Request Form
Thank you for your interest in requesting a program from The Health Promotion and Well-being Center (The Well). Our programs are now virtual! We will do our best to respond to your request as quickly as possible. If you have any questions or need to speak with someone, please contact thewell@vcu.edu or call 804-828-9355.
Email address *
Requestor's name *
Your answer
Name of Department or Organization *
Your answer
Type of Department or Organization *
Phone number *
ex. (xxx) xxx-xxxx
Your answer
Email *
Your answer
Customize Your Program
The following is a list of some of our most popular topics and programs. Descriptions of specific programs are located in the drop-down menus for each topic area. If the program you have in mind is not listed on this form, please let us know and we will work to you to see if we are able to customize a program that meets your needs.
General Requests
Alcohol and Other Drugs
Mindfulness and Stress Management
Well-being
Sexual Health
Include any additional information, special requests or accommodations needed
Your answer
How would you like this presentation delivered? *
Purpose or Goals of Your Program *
Your answer
Date *
First choice
MM
/
DD
/
YYYY
Start Time *
(for first choice)
Time
:
Alternate Date
Second choice
MM
/
DD
/
YYYY
Start Time (for second choice)
Time
:
Length of the presentation *
Second choice
Your answer
How did you hear about the Wellness Resource Center? *
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