Western Illinois University: Macomb Campus

Name: *

Age: *

Email Address: *

Phone Number: * (XXX-XXX-XXXX)

Student Status: * FreshmanSophomoreJuniorSeniorGrad Student

Major: *

Please identify which organizations you are involved in and describe as appropriate.

Student Organization: *

Athletics


Fraternity/Sorority


None

Other

Please choose one training date to attend. You must attend the entirety of the training to receive certificate.

Training Date: * Monday, January 28, 2013 6pm-9pm Monday, February 25, 2013 6pm-9pm Individual Group Request

Please choose a maximum of two topics of personal interest. Dependent upon class need, topics may or may not be covered in depth.

Topics Of Interest: *

Academics Alcohol and Alcohol Poisoning Anger
Depression Discrimination Disordered Eating
Gambling Hazing Relationship Abuse
Sexual Assault