Request for Collaboration Form 23 - 24
This form is to submit an official request for a Kean Wellness Center collaboration. Please provide your request below and include as many details about the event as possible. This request will be reviewed by the Kean Wellness Center programming committee and a response with a decision should occur in no later than 5 business days. 
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Email *
Contact Name (full name): *
Contact Cell Phone: *
What is the title or theme of the event?  *
What is the name of your department/ organization? (No acronyms) *
Select the designation that applies to your department/ organization   *
When is your event taking place? *
MM
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DD
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YYYY
What time is your event taking place? *
Time
:
If you event is taking place over several days, specify those dates and times below.
If you have already communicated with a KWC team member about this event, enter their name below.
From which Kean Wellness Center area are you requesting a collaboration? (Please note, professional staff will reach out to you from each area, if selected.) *
Select from the options below the programming areas where we can assist for this specific program *
Required
Use the section below to add any additional details or requests for your event that we would need to know about as collaborators. *
Thank you for submitting your request!  You will hear back from a member of the committee with a decision in no later than 5 business days. The academic year 23-24 committee consists of Alice Colalillo (Head of Committee), John Grady (Director of Counseling Center), Chantonette Lyles (Acting Director of the Office of Accessibility Services), Carla Vitola  (Community Care Coordinator/ Cougar Pantry), Kimberly Quinn (Coordinator of Alcohol and Other Drug Services), and Chimaobi Odumuko (Coordinator at Student Health Services).
A copy of your responses will be emailed to the address you provided.
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