Substance Abuse and Violence Education Support

Program Request Form

* Indicates required field

Group/Organization

*

Course Number

Contact Name

*

Contact Email

*

Phone Number

*

Estimated Number of Attendees

*

Intended Audience

*

Students

Faculty

Staff

Other

List all Available Dates/Dates for Requested Event (include alternative dates)

*

Location

*

Location has Computer Access? *

Location has a Projector/Projection Screen? *