University Health Services
HealthWorks
WORKSHOP REQUEST FORM
There are three ways to return this completed request form: 1. MAIL to the Office of Health Promotion and Education, room 237 Ritenour Building, University Park, PA 16802, 2. FAX to 814-865-7212 or 3. SUBMIT ELECTRONICALLY. Any questions can be directed to the HealthWorks Advisor at 814-863-0461.
1. Contact Person Information:
Your Name:
Your Position/Title:
Your Campus Address:
Phone Number:
E-Mail Address:
Best Times to Reach:
How did you hear about HealthWorks?
2. Audience Information
Name of Group:
Anticipated # of Attendees:
Has this group seen a HealthWorks workshop this year? Yes No
If yes, what?
Will this group be comprised mainly of: Men Women Both
Will this group be comprised mainly of: Freshmen Sophomores Juniors Seniors Graduates Other
3. Scheduling Information:
B. Please suggest two possible dates for the workshop, in case there is a conflict. Make sure to schedule the workshop at least two weeks in advance.
C. First Choice:
Day: Date: Time:
D. Second Choice:
4. Workshop Information:
A. What topics do you want included in the workshop? What key points do you want covered?
B. What prompted you to request this particular HealthWorks workshop?
5. Location:
A. Place
B. Directions (Where to park/unload):
C. Does the room have (check all that apply):
TV/VCR
Moveable Chairs
Overhead Projector
Blackboard or clear wall space
Screen or large clear wall
Note: If you choose to mail or fax this form, please sign and print your name below:
____________________________ Signature ____________________________ Print Name
Cancellation Policy
By submitting this form electronically, I hereby state that I have answered the above questions to the best of my abillity, and agree with all statements made within.
If you need to cancel this workshop for any reason, pelase do so at least 24 hours in advance. If HealthWorks needs to cancel this workshop, we will do so at least 24 hours in advance. For additional information, please contact the HealthWorks Advisor (Angela Ablorh-Odjidja) in the Office of Health Promotion & Education, 814-863-0461.
Form revised 9/1/00