Peer Education Program Request Form
Request a program based on the topic of interest for your class or group. This form collects essential information to help us tailor the program to your needs.
Your Name
Contact Information
Name of class, team, residence hall, student group or organization
Name of individual requesting program
Email address
Primary phone number
What topic are you interested in?
Please select...
Consent and Bystander Intervention
Mental and Emotional Well-Being
Physical and Mental Health Connection
Stress and Anxiety Coping Skills
Rest and Sleep
Relational Health and Well-Being
Have you requested or attended a BRAVE
or Peer Educator program before?
Yes
No
Select your preferred time and day
Please select...
Monday Morning
Monday Afternoon
Monday Evening
Tuesday Morning
Tuesday Afternoon
Tuesday Evening
Wednesday Morning
Wednesday Afternoon
Wednesday Evening
Thursday Morning
Thursday Afternoon
Thursday Evening
Friday Morning
Friday Afternoon
Friday Evening
Program Information
Expected number of participants
Will you provide your own advertising or would you like our team to create this?
Do you have a location reserved for the program?
Please describe any special conditions or requirements you have.
Will you be providing food and/or drinks during the program?
Contact Information