QPR 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.

Due to CAPS staff meeting time, training sessions will not be held on Tuesdays from 9-11am.

All fields are required.

Today's Date:
Requestor's Name:
Unit/Organization:
Telephone:
Email Address:

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:

Location:

workshop at CAPS:
workshop at our office:
Provide additional information to help us facilitate your request: