Wellness Outreach Request Form

Name *

Phone Number *

Email *

CU Affiliation *

Topic Requested *

Learning Outcomes *

Describe what you hope your participants will gain from attending this program. Please be specific.

Intended Audience *

CU students

CU employees

Other

Type of Presentation *

Interactive

Informational talk

Panel

Tabling

Please indicate what type of presentation you would like

Date Options *

Please list 2-3 date options, with your preferred date listed first.

Time Options *

Please list 2-3 time options (ex: 6 PM - 7 PM, 3 PM - 4:30 PM, etc.)

Estimated Number of Attendees *

Additional Information

Are you planning any other activities during the presentation? Is there any additional information you feel is relevant?

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