Requests for Programs
on Wellness Topics

Health Promotion and Community Relations provides fun and interactive programs on wellness topics. We will meet requests whenever possible or help you find other resources.

The process is as follows:

By using this form, you can request information about a program.
When we receive your request, we will forward it to the most appropriate staff member, who will call or email you to discuss your request (allow a few days for response). This interaction is key to a successful event.
Plan ahead: The more time you give us, the better we can meet your needs. Three weeks is a good amount of time.

Please answer the following questions so we can best help you.

Today's date:

→ About you...

First and last name:

Phone number with area code:

Email address:

Your primary affiliation with U-M: Student
Faculty
Staff
Other (describe below)

Organization or class (e.g. residence hall, Greek, etc):

Your role (e.g. R.A., officer, etc):

→ About your request...

Topic for your program: Alcohol and/or other drugs
Body image
Sexual health
Stress reduction / rejuvenation
Wellness
Other (describe below)

What is your goal in requesting this program?

Who will attend (estimated number and who they are)?

Preferred dates / times (List three options, or, if you have no preference, leave blank):

Option 1:
Option 2:
Option 3:

Estimated time available for program: 15-30 minutes
30-60 minutes
30-60 minutes
60-90 minutes
90 minutes or more

Location where the program will be held, if known:

How will the program be advertised? (We can offer suggestions.)

Additional comments or questions:

Send me a copy of this request via e-mail.

For more information: Call Health Promotion and Community Relations at 734-763-1320.

© 2013 University Health Service
Division of Student Affairs, University of Michigan
207 Fletcher Street, Ann Arbor, MI 48109-1050, USA
Phone 734-764-8320

Requests for Programs on Wellness Topics

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Requests for Programs
on Wellness Topics