Wellbeing Program Request Form

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 NameLast 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 locationState / Province

Postal / Zip Code
Appointment
Any other specific date and time, if the above selection is not suitable.

MonthDayYear
Date
Hour MinutesAM/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
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Program Request Form