Health Education Forms

Please fill out all information. Someone from the requested department will contact you to confirm. Submitting this request does not automatically confirm your request. Please contact Elizabeth Wilmott (x79355) if you need assistance with this form.

1. Date of Program:
2. Program Title:
3. Program/Presentation time/length and location:
4. SHAC department(s):

   • Health Education Outreach (HEO)
   • Monsour Counseling Center (MCAPS)
   • Student Health Services
5. Description of program/request:
6. Please select program topic(s):

   • Intro HEO
   • Eating Disorders
   • Stress Management
   • Intro MCAPS
   • Listening Skills
   • Time Management/Study Skills
   • Intro SHS
   • Relationships
   • Alcohol
   • Sexual Assault
   • Body Image
   • Drugs
   • Sexual Health
   • Other
7. Program is for which department or organization:
8. Expected number of attendees:
9. Intended audience:

   • Students
   • Faculty
   • Staff
10. What is your name, email address, and phone number?

    • Name:
    • Email:
    • Phone:
11. Your institution:

    • Pomona
    • CGU
    • CUC
    • Scripps
    • Claremont McKenna
    • Harvey Mudd
    • Pitzer
    • KGI
12. Your status:

    • Student
    • Staff
    • Faculty