Western Illinois University: Macomb Campus

Person making request:*

Position/Title:*

Address:*

Phone: (XXX-XXX-XXXX)

E-mail address:*

Name of organization, group, class:*

Program/Presentation Topic (check all that apply):*
Interpersonal Violence Domestic/Dating Violence Sexual Assault
Stalking Consent Bystander Intervention
Other (please specify)

Title of Program (if applicable):

Date Program/Presentation to be held:* (please allow at least 2 weeks from date of request)

Time Program/Presentation to begin:*

Program/Presentation length:*
15 min. 30 min. 45 min.
60 min. 75 min. Other

Location Program/Presentation to be held:*

A/V Equipment Needed:

Alternative dates/times:

Nature of group/target audience:

Estimated attendance:

Please add any additional information that may aid in planning the presentation:

Publicity will be done by:*
Person making request IVPI Staff Other

Date publicity needs to be out:

Room will be reserved by:*
Person making request IVPI Staff Other

Equipment will be reserved by:*
Person making request IVPC Other

Requested Speaker (in addition to Interpersonal Violence Prevention Coordinator):*
Counseling Center Staff OPS Officer Judicial Programs Staff
Victim Services Staff/Volunteer Sexual Assault Nurse Examiner MEN (Men Endorsing Nonviolence)
Faculty Researcher Beu Health Education Staff
Other (please specify)