MSL Diversity Educators Facilitation Request Form
Complete this form to request an MSL Diversity Educators facilitation. Please be as detailed as possible in your request. All requests must be submitted 2 weeks in advance of desired program date. NOTE: MSL Diversity Educators will not be able to facilitate on Tuesdays from 2:00 PM - 4:00 PM or on Thursdays from 1:00 PM - 4:00 PM for the spring 2017 semester.
First Name
Your answer
Last Name
Your answer
Email Address
Your answer
Phone Number
Your answer
Department/Organization Name/Course Name
Your answer
Desired Date of Program
MM
/
DD
/
YYYY
Desired Facilitation Start Time
Time
:
Desired Facilitation End Time
Time
:
Desired Location
On campus building & room number
Your answer
Estimated Number of Participants
Your answer
Please select the activities you would like the MSL Diversity Educators to faciliate.
Please provide the MSL Diversity Educators with any information about your group that you believe would be helpful in preparing your facilitation.
Include any group dynamics, special needs, challenges, etc.
Your answer
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