Health Center Program Request Form
Due to the high volume of requests our office receives for programming, we ask for a 1-week notice on requested program dates.

Contact Information

Name

Email

Phone

Prefer to be contacted by Email Phone Either

Audience

Audience Description

Audience Gender Male Female Both

Audience Age/School Year

Expected Attendance

Organization/Class Name

Event

Requested Topic

Event Name

Location of Program

Preferred Date

Preferred Time

Alternate Date

Alternate Time

Other

Comments

Requested Presenter

Equipment Available at Location Computer
LCD Projector
Overhead Projector
Projection Screen
Ethernet
Wireless
TV/VCR
TV/DVD Player
Paper & Easel
Dry Erase Board

Type of Advertisements Flyers/Posters
Voicemail
Banner
Internet
Handbill
Other (specify in comments)