Workshop and Presentation Request Form

Name:

E-mail:

Phone:

Affiliation to the University: Student Grad Asst. Staff Faculty Not Affiliated

Organization/Department/
Class

Program Topic:

Program Title:

Nature of the Program Requested Educational Presentation Informational Table Other

Goals for the requested program and/or related audience needs:

Preferred Date and Time

Alternate Date and Time

Preferred Length of Program

Access to Technology:

• Computer
• Projector
• Sound System
• Technical Assistance in Person

Audience Description (e.g., Freshman, Females, Graduate Assistants etc.)

Number of Participants Expected (with minimum of 10)

Attendance:

• Mandatory
• Optional

Please provide an additional information that may help us facilitate your request