Outreach/Training/Assessment Request Form

Name of Person Making Request:
Position/Title of Person:
Address (for correspondence):
Office Phone (if applicable):
Home/Cell Phone:
Email:
Best Way to Get in Touch with the Contact Person:	Office Phone Home Phone Email
Desired Day and Date for the Presentation/Assessment:
Desired Time for the Presentation/Assessment:
Desired Length for the Presentation/Assessment:
Location/Place for the Presentation/Assessment:
Intended Audience for the Presentation/Assessment:
Anticipated Number of Persons in Attendance:
Presentation Topic or Assessment Instrument:
Brief Description of the Purpose/Goals of Presentation/Assessment:
Other Notes of Interest:

Once UCS receives your request, we will send you an e-mail message acknowledging that we have received it. UCS staff typically meet once each week and presentations are assigned to staff members at that time. You will then either receive a confirmation e-mail informing you which staff member will be conducting the program or explaining why we are unable to fulfill your request at this time.