SCS Outreach Request Form
Please complete the information below to the best of your ability. Our outreach coordinator will get in touch with you about filling your request. If you have questions, contact Brenna Wernersbach at wern0146@umn.edu or 612-626-7313.
Email address
Type of service
Brief Description (topic, audience, specific focus, goals, etc. )
Your answer
Department or organization name
Your answer
Requester's name
Your answer
Requester's email address
Your answer
Requester's phone number
Your answer
Date of requested program
MM
/
DD
/
YYYY
Time of requested program
Time
:
Length of requested program
Your answer
Location of requested program (building and room number)
Your answer
Estimated number of students
Your answer
Additional information
Your answer
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
Submit
Never submit passwords through Google Forms.
This form was created inside of University of Minnesota Twin Cities. Report Abuse - Terms of Service - Additional Terms