Custom Program Request Form - Students

Future Students

Undergraduate Students

Graduate Students

Parents & Family

Alumni

Faculty & Staff

Researchers

Patients

Colleges & Schools

Request a Program

Name(*)

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Email(*)

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Phone number (*)

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Department, Academic Course, or Student Organization(*)

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Preferred contact method(*)

Phone

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Location of Requested Program (*)

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Requested Date and Time of Program(*)

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Secondary Date and Time of Program(*)

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Type of Program:(*)

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Workshop

Blazer Wellness Jeopardy (50-75min)

Wellness Bingos (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)

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Tabling

General Department

Bartending 101 – Standard Drink Pouring

Intimacy Timeline

Condom Lineup

Wellness Topics on Demand

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Additional information about the program you are requesting:

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How will your program be advertised? (*)

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If requesting a custom program, what are the intended learning outcomes of your program?

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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.(*)

I agree

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Verify Captcha(*)

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