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PROGRAMMING REQUEST FORM

Center for Counseling and Student Wellness
Programming Request Form

Requestor Information

First Name:

Last Name:

Campus Position:

Faculty

Staff

Student

Other (Please specify)

Campus Department or Organization:

Phone:

Email:

Presentation Information

Presentation Topic:

Primary Presentation Goals:

What space do you anticipate having for this event (e.g. classroom, library, large hall such as Vandervort, etc)?
If you're unable to reserve your first choice, please simply let us know about any changes:

Number of Expected Attendants:

Audience (e.g. first-year students, seniors, faculty, student organization(s) or team(s), community members, etc.):

Please select a time and date. Providing a primary and secondary choice along with making your request in advance (i.e. at least 1-2 weeks or more) makes it more likely that we will be able to accommodate your request.

Primary Date and Time Options

Start Time:

AM

PM

Day:

Date:

Presentation Length (minutes):

Secondary Date and Time Options

Start Time:

AM

PM

Day:

Date:

Presentation Length (minutes):

Other Information

Any other questions or comments:

Upon submission of this program request form our CCSW staff will be in contact with you to finalize this program request. We look forward to working with you soon.

 

CONTACT

91 St. Clair Street
Geneva, NY 14456

Phone: (315) 781 - 3388
After Hours Emergencies: (315) 781-3333

Hours: Monday - Friday 9 a.m. - 5 p.m.