Program Request Form - Department of Student Affairs, University at Buffalo

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Wellness Education Services

Program Request Form

Please complete the following form to request a program from Wellness Education Services. When your request is received, we will contact you to confirm. All programs require at at least two weeks advance notice. Please collaborate with others and advertise to ensure participation.

First Name: Last Name:

Position:

Organization, Class, Club, etc.:
Or other:

Program Topic:

Time & Date (1st Choice): Start Time: AM PM Date:
Program Length: minutes

Time & Date (2nd Choice): Start Time: AM PM Date:
Program Length: minutes

Contact Person:

Best Time to Contact:

Best Phone Number: Ext.:

E-Mail:

Location for Program:

Number of Attendees:

Requests/Comments

Wellness Education Services
114 Student Union
University at Buffalo
Buffalo, NY 14260-2100
Tel: (716) 645-2837
Fax: (716) 645-6234
Contact: Sherri Darrow
E-Mail:
General

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Related Documents

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