Peer Education Presentation Request Form
PLEASE NOTE: IN ORDER TO BEST PREPARE AND TRAIN OUR PEER EDUCATORS, WE WILL NOT BE ACCEPTING ANY PRESENTATION REQUESTS SCHEDULED BEFORE SEPTEMBER 18TH.

We ask that requests be made AT LEAST TWO WEEKS prior to the date of the desired presentation. It may take up to two weeks for us to process, staff, and confirm your request.

Program Request Information
For more detailed descriptions of each peer presentation, please visit: http://health.umd.edu/peerpresentations.

Please note:
*Sexual Health (SHARE) programs will run differently this year, please contact jbeckwit@umd.edu for more information.
*To request Eating Your Way Through College (Presented by SNAPS), please email jjakubcz@umd.edu.
*For a general Health Center overview presentation, please contact argentin@umd.edu.

Peer Program Requested *
First Choice Date and Time *
MM
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DD
/
YYYY
Time
:
Second Choice Date and Time *
MM
/
DD
/
YYYY
Time
:
Location/Building Name *
Your answer
Room # *
Your answer
Name of Group, Class, or Residence Hall *
Your answer
Some programs require techology. What best describes the technology in your classroom/space? *
If the program you requested requires technology and you do not have it avaialble, the program coordinator will work with you to accomodate your needs.
Contact Information
Preferred Name *
Your answer
Preferred Phone *
Your answer
Alternative Phone
Your answer
Email *
Your answer
How did you hear about us?
Your answer
For Resident Assistants and Residential Programming Only
Name of Resident Director/Supervisor
Your answer
Email address of Resident Director/Supervisor:
Your answer
Phone number of Resident Director/Supervisor
Your answer
Group Information
Will the instructor/group leader be present for the presentation? *
Audience Size *
Must be at least 10
Your answer
Short description of audience
Your answer
We strive to create accessible spaces during all of our presentations. Please let us know of specific accommodations your class, group, or residence hall may need to succeed.
Your answer
Other /Special Instructions
Your answer
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