Outreach Program and Psychoeducational Workshop Request Form

Please provide the following information so that we may process your request. All program requests must be submitted three weeks prior to the date of the intended program.

All fields are required.

Today's Date:
Requestor's Name:
Class/Organization:
Requestor's Position:
Telephone:
Email Address:
Brief Description of Workshop or Topic Requested:
Reason for Request/Perceived Need:

Preferred Dates / Times (You may list three options. If you have no preference, leave blank):

option 1:
option 2:
option 3:

Time Allotted for Program:
Number of Participants Expected:
How will the program be advertised?
Room/Building where the program will be held:
Provide additional information to help us facilitate your request:

3100 Michigan Union, 530 S State Street • Ann Arbor, MI • 48109 • voice 734.764.8312 • fax 734.763.0454 • Mon-Thurs 8-7,
Fri 8-5 (Fall/Winter) Mon-Fri 8-5 (Spring/Summer)