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Peer Education Presentation Request Form
Please make your request at least 2 weeks prior to the date of the desired presentation.
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* Indicates required question
Contact Information
Preferred Name
*
Your answer
Preferred Phone
*
Your answer
Alternative Phone
Your answer
Email
*
Your answer
How did you hear about us?
Your answer
Other /Special Instructions
Your answer
For Resident Assistants and Residential Programming Only
Name of Resident Director/Supervisor
Your answer
Email address of Resident Director/Supervisor:
Your answer
Phone number of Resident Director/Supervisor
Your answer
Program Information
For more detailed descriptions of each peer presentation, please visit:
http://health.umd.edu/peerpresentations
Program Requested
*
Choose
In Sickness and In Health - General Health Center overview (Presented by SHAC)
The Mind Body Connection (Presented by HEALTH Works)
It's Time to Talk about Mental Health (Presented by HEALTH Works)
Eating Your Way Through College (Presented by SNAPs)
Sexual Assault Overview (Presented by CARE)
Stalking (Presented by CARE)
Relationship Violence (Presented by CARE)
Step Up! - Specifically focused on sexual assault (Presented by CARE)
The Ins & Outs of Safer Sex (Presented by SHARE)
Safer Sex Workshop (Presented by SHARE)
Alcohol 101 - A conversation about alcohol in the college environment (Presented by CHOICES)
Drugs 101 - Drugs commonly abused in college eg: marijuana, prescription drugs, & tobacco (Presented by CHOICES)
Step Up! - 50 minutes
Step Up! - 90 minutes
First Choice Date and Time
*
MM
/
DD
/
YYYY
Time
:
AM
PM
Second Choice Date and Time
*
MM
/
DD
/
YYYY
Time
:
AM
PM
Location of Program Building
*
Your answer
Room
*
Your answer
What best describes the technology in your classroom?
*
Choose
My classroom has built in technology (computer, projector).
I will arrange for technology to be brought to the classroom.
I do not have access to technology in my classroom.
Group Information
Name of Group, Class, or Residence Hall
*
Your answer
Will the instructor/group leader be present for the presentation?
*
Yes
No
Audience Size
*
Must be at least 10
Your answer
Short description of audience
Your answer
We strive to create accessible spaces during all of our presentations. Please let us know of specific accommodations your class, group, or residence hall may need to succeed.
Your answer
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