Fillable Longwood University Counseling Center Outreach Program/Presentation Request Club/Organization/Class (Longwood University)

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Longwood University Counseling Center Outreach Program/Presentation Request Club/Organization/Class (Longwood University)

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Longwood University Counseling Center
Outreach Program/Presentation Request
Your Name: Today’s Date:
Club/Organization/Class You Are Representing: Estimated Number Of
Participants:
Your Phone:
Your Email:
Topic Of Presentation/Program:
Preferred Date/Time Of
Presentation/Program:
Requested Presenter:
Location Of Presentation/Program: Length Of Presentation/Program:
Description Of The Presentation/Program:
How Will This Presentation/Program Be Publicized?
*FOR INTERNAL USE ONLY*
Date Request Received: Date Request Reviewed:
Presenter: Date & Time Of Program/Presentation:
Resources Needed:
Communication Tracking
Date Of Contact Progress Next Step
Outcome
Program/Presentation Title:
Date: Length: Number of Participants:
Comments:
Needed Follow-Up:
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Longwood University Counseling Center Outreach ProgramPresentation Request ClubOrganizationClass (Longwood University)

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Completed 22 August 2020

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