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Student Services

SHEP Workshop Request Form

 

Contact Person Information
Today's date
Name
Title (e.g. health worker, RA, president)
Email Address
Phone Number
How did you hear about us?
Participant Information
Name of Group
Anticipated # of participants
This group will be comprised mainly of: men

women

 both
This group will be comprised mainly of (mark all that apply):

Freshmen
Sophomores
Juniors

 Seniors
Grad students
Other information about the group:
Workshop Information
What information would you like covered during the workshop? (Check all that apply.)

safer sex
sexual pleasure
birth control
STIs
alternatives to sex

sexual response/orgasm
women's health
LGBTIQ sexual health
pelvic exams
Other:
What formats do you prefer? (Check all that apply.) Lecture
Fishbowl (anonymous Q&A)
Games
Discussion
Other:
Scheduling Information
Please suggest two possible dates for the workshop, in case there is a conflict. In order to fulfill your request, we need a minimum of one-week advance notice of your workshop. Please plan ahead!
1st choice:

Date:
Start time:

Day:
End time:

2nd choice:

Date:
Start time:

Day:
End time:

Location:
Special Requests
We will do our best to meet your specific needs, but unfortunately we cannot promise that we will be able to accommodate all requests.
I would prefer two female presenters.

I would prefer two male presenters.

I would prefer a male and a female presenter.

I would prefer a presenter from a specific community (e.g. LGBTIQQ, Greek, African-American, athlete, etc.):

I would prefer a specific peer educator named .
Any other comments or requests?
Submit Form
After you submit the form, you will be taken to a confirmation page.
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