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CAPS Outreach Request Form
Contact Information
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* Indicates required question
Name
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
UVa Affiliation
*
Student Affairs Department
Academic Affairs Department
Residence Hall
Student Group
Non-UVa affiliation
Other:
Department/Res Hall/Group/Organization Name
*
Your answer
Programming Description
Type of Program
Presentation
Facilitated Discussion or Dialogue
Informational Table
Panel Participation
Event Attendance/Counselor Available for Support
Other:
Topic Requested
*
Your answer
Preferred Presenter(s)
Your answer
Audience
*
Who will we be speaking to? Please select all that apply.
Students
Faculty
Staff
Community Members
Other:
Expected Number of Participants
*
Your answer
Location for Outreach Program
*
Your answer
Scheduling
Please specify duration of program -- approximately how long would you like the provided programming to be, in hours and minutes. Please provide two or three options for the time and date.
Duration
*
Your answer
Preferred Dates/Times of Program, Option 1
*
MM
/
DD
/
YYYY
Time
:
AM
PM
Preferred Dates/Times of Program, Option 2
MM
/
DD
/
YYYY
Time
:
AM
PM
Preferred Dates/Times of Program, Option 3
MM
/
DD
/
YYYY
Time
:
AM
PM
Technology/Materials Availability
Technology/Materials Available and Provided
Please check all that apply.
Projector
Laptop
Speakers
Board
Other:
Other Information
Please provide any additional information about the topic, audience, department, level of training, cultural considerations, or other general preferences that will assist us in better tailoring the program to the group’s needs.
Your answer
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