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Custom Program Request Form
Outreach & Workshops
Custom Program Request Form
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Department, Academic Course, or Student Organization
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Phone
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Location of Requested Program
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Requested Date of Program
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Requested Time of Program
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Secondary Date of Program
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Secondary Time of Program
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Type of Program:
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Workshop
Tabling
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Workshop
Workshop
Blazer Wellness Jeopardy (50-75min)
Healthy Relationship Kahoot (45 min)
Time Management (45min)
Bystander Intervention (45min)
Let’s Talk: Sex & Relationships (50-75min)
Alcohol Safety 101 (30min)
A Journey to a Healthy Relationship (30-50min)
Wellness Bingos (50-75min) (A selection box will appear below to choose your program)
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Wellness Bingos (50-75min)
Wellness Bingos (50-75min)
Sex & Booze: Covers consent and alcohol safety
Booze & More: Focuses on alcohol, tobacco, and other drugs
Sleep and Stress: Covers commons stressors, healthy sleep habits, and coping mechanisms
Safe and Sexy: Covers safer sex practices and consent
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Tabling
Tabling
Department Information & Services
Bartending 101 – Standard Drink Pouring
Intimacy Timeline
Condom Lineup
Wellness Topics on Demand (A selection box will appear below to choose your topic)
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Wellness Topics on Demand
Wellness Topics on Demand
Self-Care
Substance Use
Sleep
Healthy/Unhealthy Relationships
Consent
Boundaries
Bystander Intervention
Sexual Health
Feel Your Best Campaign
Behaviors
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Additional information about the program you are requesting:
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What is the estimated attendance of your program ?
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I understand that submitting this request does not guarantee that a program has been reserved. I also understand that program requests must be submitted with sufficient advance notice to allow for planning and coordination. A member of the Wellness Promotion team will follow up to confirm availability and finalize program details.
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I understand that submitting this request does not guarantee that a program has been reserved. I also understand that program requests must be submitted with sufficient advance notice to allow for planning and coordination. A member of the Wellness Promotion team will follow up to confirm availability and finalize program details.
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