LICAB Workshop Request Form

Workshop/Presentation Request Form
The Long Island Coalition Against Bullying is proud to offer the community a variety of workshops and presentations related to bullying. Our team can prepare workshop presentations and customized workshops to meet your needs.

The accommodate your needs for a successful workshop(s), we require adequate time and finding the available presenters. We require this workshop request form submitted at least 30 days in advance for most workshops.

Please provide the information below and we will contact you to confirm our commitment to provide the requested workshop.

* Workshops fees will be discussed and proposed once the scope of work has been assessed*
Name of Organization or School*
Name of School District (if applicable)
Contact Name*

First NameLast Name
Contact Phone Number*
Please enter a valid phone number.
Contact E-Mail Address*
example@example.com
Location of Workshop/Presentation*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date & Time for Workshop

Please pick three possible dates to maximize accommodations for all requests we receive. We will make all efforts possible to accommodate the dates requested. Dates cannot be within 30 days of the date of completion of the request.
Preferred Date #1*

MonthDayYear
Date
Preferred Date #2*

MonthDayYear
Date
Preferred Date #3*

MonthDayYear
Date
Workshop Description
Type of Workshop

Elementary Age ProgramMiddle/High School Age ProgramParent/PTA ProgramStaff/Faculty
Estimated Number of Students*
Estimated students who will have participated in the presentations by their conclusion(s).
Estimated Number of Faculty/Staff*
Estimated students who will have participated in the presentations by their conclusion(s).
Estimated Number of Parents*
Estimated students who will have participated in the presentations by their conclusion(s).
What is the goal or purpose of the workshop?*
A short description of the participants including demographics (if possible):*
Describe any workshops that have been conducted prior. Will there be any after ours?*
Any other requests or comments that would help us better prepare for your requested workshop:*
For Internal Use Only

The below is to be completed by LICAB staff only.
Workshop/presentation confirmed

YesNo
Date(s) agreed to
Planning meeting notes
Should be Empty:

Workshop/Presentation Request Form

Date & Time for Workshop

Workshop Description

For Internal Use Only