Health Promotion Program Request

• Alcohol 101
• General Health and Student Health & Wellness
• HIV/AIDS - Just the Facts
• Sexual Health - Sexually Transmitted Infections Prevention
• Stress and the MindBody Connection
• Sex and Alcohol - They Don't Mix
• Other health related topics upon request

Would you like Student Health & Wellness to participate in a program that you are hosting such as a Roo Fair, organization program, health and wellness fair, etc.? Please complete the request form below and the Health Educator will get back with you as soon as possible to confirm your request. Please note that a minimum of two weeks lead time is requested. Please provide as much detail about your program and the intended audience.

Thank you for your interest in Student Health & Wellness.

Name
Phone
E-mail
Class/Organization
Type of program:	---choose from this list--- Health & Wellness Fair Information Fair Organization program Contraceptives Presetation Sexual Health - STI Prevention Stress and the MindBody Connection My Plate: Healthy Eating HIV/AIDS: Just the Facts Other - explain in Comments box
Proposed date
Alternative date
Proposed time
Alternative time
Number of participants expected
Location
Organization	---choose from this list--- Community Agency Residential Life Fraternity and Sorority Life Student organization UMKC Department Other*
* If you selected other from the organization menu above, please list your organization
What has prompted you to request this presentation?
Provide details about event and intended audience.