Program Request Form

Lewis University’s Center for Health and Counseling Services staff is available to do presentations, workshops, and trainings at your request on various health topics. If you are interested please complete the program request form.

Program request must be made at least 2 weeks prior to the requested program date. You will be notified of our availability within 3 business days of your request.

Please note: Availability is on a first-come, first-serve basis. If we are unavailable at your requested time we will work with you to find an alternative date. Also, if requesting a presentation, access to PowerPoint and the internet is required.

See Program Descriptions >>

Applicant Information

*First Name:
 

*
Last Name:
 

*
Address:
 

*
City:
 

*
State:
 

*
Zip Code:
 

*
Phone Number:
 

*
Email:
 


Please provide information for an alternative contact

*Alternate First Name:
 

*
Alternate Last Name:
 

*
Alternate Email:
 

*
Alternate Phone Number:
 


*Requested Program Topic(s):


See Program Descriptions >>


If you selected other, please describe the type of programming you are interested in:



Please enter the date and time of the requested program

*Program Date:


*Program Time:


Please provide an alternative date and time for requested program

*Alternate Program Date:
  

*Program Time:




*How long is the program (i.e. 1 hour)?
 

*Will we be expected to speak for the entire program?
 Yes
 No  

If you responded “no” to the previous answer, what is our time allotment?


*Please enter the location of your program. Include the building, room number and any special instructions that may be needed to gain entrance to the building



*How would you describe yourself?
 Student
 Faculty
 Staff  


*Is this presentation for a student organization?
 Yes
 No  

If yes, what is the name of the organization?




*What is the make-up of your audience (i.e. freshman, professors, athletes, etc.)?
 

*Expected Attendance
 


Please list any other special requests, questions, or concerns.