Program Request Form

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If you are interested in having a health education program presented by the staff of WesWell, please complete all information below. Please attempt to submit your request at least three weeks in advance to ensure your preferred date and time.

Name *

Email *

Telephone *

Residence Life Staff members:

If you are requesting this program for your residents, indicate which hall/house(s) will be invited.

Student Organizations:

If you are requesting this program on behalf of a student organization, indicate which group(s).

I am interested in the following program: *

Navigate back to the Program Description page to read about each.

Bartender's School

Healthy Relationships

WesSex

Massage for Stress Relief

Getting Better Sleep

Sexual Assault - We Speak We Stand

Alcohol - We Speak We Stand

Stress Relief Practicum

Mindfulness Practicum

Me, Myself and Marijuana

Supporting Survivors

Healthy Hook-ups

Required

If the topic you are interested in is not listed above, please describe it here.

Please be as specific as possible, e.g. "Addressing Alcohol Poisoning" rather than "Alcohol".

Approximate number of people expected to attend *

First choice of date *

Second choice of date *

Preferred start time *

specify AM or PM

Program Location *

Any other information that could be helpful or that doesn't fit into the above categories?

Processing your request.

You will be contacted within one week to discuss your program request in more detail.

If you wish to cancel or change your request, please email weswell@wesleyan.edu or call 860.685.2466 as soon as possible. Thank you!

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