Program Request Form
We have a variety of 30-45 minute Wellbeing programs to choose from. Please see below for options. Choose ONE from the 3 categories provided: Community Series, THRIVE Series, or Custom.
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Community Series (Choose one if applicable)
THRIVE Series (Choose one if applicable)
CUSTOM program request (Choose one if applicable)
Target Population
*
Location
*
Building
Classroom # (if applicable)
Program set-up location
State / Province
Postal / Zip Code
Appointment
Any other specific date and time, if the above selection is not suitable.
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
More information about your event (If not, type N/A)
*
Contact us
Wellbeing@southernct.edu | (203)392-7330 | Business Hours: Mon-Fri, 8:30AM - 4:30PM
Submit
Should be Empty: