The University of Scranton - Center for Health Education and Wellness

Center for
Health
Education
and
Wellness

REQUEST A PROGRAM

Complete and submit this form to request a CHEW staff or COPE/peer education program at least two weeks in advance of your desired program date. We will get back to you within five working days of your request. For a list of available and example programs please review our programming menu.

1. Select a presentation group:
		COPE (all peer presentation)
		CHEW professional staff

2. Select a team to present:
		Late Night Programming Team
		Alcohol and Drug Prevention Team
		Tobacco Team
		HIV/AIDS and STI Prevention Team
		Nutrition Team
		Mental Health Team
		Physical Activity Team
		Other (please specify)

3. Please identify a topic for your presentation:

4. In order of preference, what "two" optional dates and times would you like to hold the program?

	First Choice			Second Choice
	Date (mm/dd/yy)			Date (mm/dd/yy)
	Time (00:00 AM/PM)			Time (00:00 AM/PM)

5. For whom is the program being requested (group, class, etc.)?

6. How many attendees do you expect?

7. Where will the presentation be held (building and room #)

8. Please complete your contact information:
	a. name
	b. e-mail address
	c. phone number

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