Workshop/Presentation Request Form
Thank you for your interest in a Wellness Promotion and Education program. Please plan
ahead and make your request at least two weeks in advance of your preferred date. If you
need assistance completing this form please contact us at 805-437-3521 or We look forward to working with you!
Today's Date
Phone number
Affiliation to CSU Channel Islands
Department or Student Organization name
Wellness Promotion & Education is able to provide training workshops and educational
presentations on topics such as; alcohol, contraception, general wellness, healthy eating, sexual
and reproductive health, stress management, sleep hygiene, and tobacco/hookah/e-cigs. At times
we may be able to develop a customized workshop based on your request. Please note that
trainings are intended for groups of 5 or more participants.
Suggested title for your workshop/presentation
Please provided additional information about your workshop/presentation request
Preferred date
Alternative Date
Preferred start time Alternative start time
Preferred end time Alternative end time
It is the responsibility of the requestor to reserve a location for the requested workshop/
presentation. If you require assistance with this process please contact Wellness Promotion and
Education at 805-437-3521.
Expected number of attendees
Less than 5
6 - 10
11 - 20
21 - 30
31 - 40
41 - 50
51 or more
How do you plan to advertise this workshop/presentation?
Additional comments about this request.
Thank you for submitting your request. A representative from Wellness Promotion and Education
will contact you with in 24 hours to confirm and to clarify any questions regarding this request.
Best Regards,
Wellness Promotion and Education