Outreach Request Form

* Name of requestor:

* WKU Email:

* Phone:

* Department:

* Role on campus:

If for an Organization, please list organization and your role:

College (if applicable)

For classroom presentation, please list class name and location:

* Outreach Topic:

If not list above, what other topic or combination of topics would you like?

Are you requesting an interview with a staff member?

If yes, what’s the purpose/topics of the interview?

If you are requesting an interview will it be used for one of the following:

Are you requesting a specific staff member?

* Length of Outreach:

* Location: Please list specific location (e.g., Cherry Hall 236, Gilbert Hall study room, regional campus, XYZ chapter house, DSU 3020)

Residence Hall:

* Zoom (requestor is responsible to schedule zoom session and share link with the Counseling Center, PRIOR to the outreach)

* Estimated number of people expected:

* Audio/Visual equipment available for the presentor:

Special accommodations needed? Please list below:

Please list below any other important information you would like to share with our staff presenter.