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Health Education Presentation Request Form
Presentation Organizer Information
First Name
Last Name
Telephone Number
Email
Role on Campus
Student
Staff
Faculty
Requesting Office/Dept/Organization:
Presentation Information
Preferred Date & Time
Preferred Date & Time: Date
Preferred Date & Time: Time
Alternate Date & Time
Alternate Date & Time: Date
Alternate Date & Time: Time
Format of Presentation
Virtual
In-Person
Location of Presentation, if applicable (Bldg. and Room No.)
Address of Location, if applicable
GT Course information (only if applicable) (Ex: GT1000, APPH, Etc.)
Estimated number of participants
Which topic would you like to request for your presentation?
8 Dimensions of Wellness
Alcohol
Resilience
Sexual Health
Stress Managment
Self-care
Partnership Information and Accommodations
How would you like the Wellness Empowerment Center to assist with your presentation?
I would like the Wellness Empowerment representative to facilitate this program
I would like to co-facilitate this program with Wellness Empowerment staff
I would like to facilitate the program on my own, but I would like advice/ support/ resources beforehand from Wellness Empowerment staff
Is there any other information that you would like to share about your request?
Are there any accommodations needed for your presentation/event?
Leave this field blank
