Substance Abuse Prevention Education
Program Grant Request Form
Program Title:
*
Location of Program:
*
Date of Program:
*
-
Month
-
Day
Year
Date
Time of Program:
*
Hour Minutes
AM
PM
AM/PM Option
Program Description:
*
Collaborators/Partners:
Budget:
*
Please itemize all costs associated with the program (Item, Quantity, Price, & Total)
Approximate Total Cost for Event:
*
Amount Requested from SAPE Grant:
*
Program Format (indicate at least one):
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Seminar
Lecture
Panel Discussion
Case Study
Speaker
Video
Experiential Learning
Other
Target Audience (indicate at least one);
*
Residence Hall
Fraternity/Sorority
Other Registered Organization
Athletic Team/Sport Club
Class
Professional/Paraprofessional Staff
Other
Publicity
*
Describe the means by which the program will be promoted within the WIU community.
Program Coordinator Information
Name
*
First Name
Last Name
Campus Address
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: