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Request a Program

Complete and submit this form to request a CHEW staff or COPE/peer education program at least two weeks in advance of your desired program date. We will get back to you within five working days of your request. For a list of available and example programs please review our programming menu.    Click Here

1. Select a presentation group:
  COPE (all peer presentation)
CHEW professional staff
     

2. Select a team to present:
  Late Night Programming Team
  Alcohol and Drug Prevention Team
  Tobacco Team
  HIV/AIDS and STI Prevention Team
  Nutrition Team
  Mental Health Team
  Physical Activity Team
  Other (please specify) 

3. Please identify a topic for your presentation:

4. In order of preference, what "two" optional dates and times would you like to hold the program?

  First Choice   Second Choice
  Date (mm/dd/yy)   Date (mm/dd/yy)
  Time (00:00 AM/PM)   Time (00:00 AM/PM)

5. For whom is the program being requested (group, class, etc.)?
     

6. How many attendees do you expect?  

7. Where will the presentation be held (building and room #)
     

8. Please complete your contact information:
  a. name
  b. e-mail address
  c. phone number

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