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Program Request Form

Thank you for considering CSDC for your programming needs. The following information will help us develop appropriate and effective programming for your request. Simply complete this form, then click on the Submit button at the bottom. A member of the CSDC staff will contact you as soon as possible. All program requests must be submitted to CSDC 2 weeks prior to program date. Of course exceptions will be made for any crisis intervention programming.

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1. Program Information:

  • Topic and reason for request:

 

  • Date:

  • Time:

  • Location:

  • Handouts, materials requested:

  • Audience information (i.e., fraternity/sorority, classroom, residence hall floor, student organization):

  • Are special needs of audience members being addressed (i.e., interpreters, wheelchair access, etc.)?

 

2. Contact information:

  • Name of organizer:  

  • Relationship of organizer to audience:

  • Phone number:

  • Best time to contact organizer:

  • E-mail address:

  • How often do you check your e-mail?

3. Any additional information that would be helpful as we develop a program to meet your needs:

4. Marketing and Attendance (If this is a classroom presentation, please disregard this section).

  • How is this program being marketed? (i.e. flyers, Northern Star, television, local newspaper, word of mouth, mandatory program)

  • Date marketing campaign begins:

  • Expected audience numbers:

 
(For an effective presentation, we need a guarantee of at least 10 audience members).

5. Please select the appropriate program description box:

 Coaching for Academic Success (study skills, time management, etc.)

 Other topics (relationships, stress management, etc.)

 

For additional information about CSDC's programming, contact Diane Pospisil-Kinney at (815) 753-1206.