Presentation Request

Topic:

(Topic you wish to be discussed)

Date(s):

(Dates you would like the presenter to present topic)

Alternate Date(s):

(Dates you would like the presenter to present topic if first choice is not available)

Time(s):

(Times you would like the presenter to present topic)

Alternate Time(s):

Program Site:

(Place where presenter arrives to present the topic)

Contact Person:

Phone No.:

(Where contact person can be reached)

Alternate No.:

Organization:

(Description of attendees being addressed: i.e.: class, hall, program, etc.)

Number of Participants:

(Estimated Number of Participants)

Type of Service:

Sexual Assault

Domestic Violence

Helping a Friend

Peer Educators

Dating Violence

Links