Wellness Outreach Request Form

Wellness Outreach Request

Wellness and Health Promotion Services is a department of Student Health Services
Please submit your request at least 2 weeks in advance of your event. Presentations for Residence Halls require a commitment of at least 3 floors.
Name: *

First Name Last Name
E-mail *
Phone Number *
Affiliation to SIU:
Preferred Date of Presentation: *

Month Day Year
Date
Preferred Time of Presentation: *

: Hour Minutes AM/PM Option
Alternative Date:

Month Day Year
Date
Alternative Time of Presentation:

: Hour Minutes AM/PM Option
Length of Presentation Time:
Example: 30 minutes, 45 minutes, 60 minutes etc.
Location of Presentation:
Please include the name of the building, department, and room number.
Please describe the topic(s) you would like presented upon:
Topic areas may include orientation to Student Health Services, physical, nutritional, and sexual health, alcohol and other drug harm reduction, violence and suicide prevention, stress management, resilience and coping skills, and healthy equity and inclusion.
Audience Description:
Expected Number of Participants:

10 - 20 people 21 - 30 people 31 - 50 people 51 - 75 people More than 100 people
Is there audio/visual equipment available at the location of the presentation? *

Yes No Limited I don't know
If yes, please describe what audio/visual equipment is available for the presenter at your location:
Tell us anything else we need to know:
Should be Empty: