Outreach Program Request Form

If you would like the UCC to present an outreach program, please complete and submit the form below. Once the request is received, a staff member will contact you to discuss the details. Please provide at least three weeks notice before an outreach event.

Full Name: *

Name of your Department/Program/Organization:*

Position/Title/Role:*

Email: *

Phone (with area code):*

Date(s) of the Event:*

Day of Event Contact (if different than above). Please include name, phone, and email:

Start and End Time of Event (please include if time is flexible):*

Event Location (Address/Building/Room Number):*

Tell us about your event and what you would like from us:*

Anticipated number of attendees (example: 25 students):*

By checking this box I recognize and understand that my email address is provided solely for inquiries about the UCC and its outreach functions. I understand that this is not a form of contact for clinical treatment or help in emergency. If I do need clinical treatment I must call or visit the University Counseling Center during office hours. If this is an emergency, please call 911.

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