Chicago CAPS Outreach Request Form

Name Name First Last
Phone Phone - ### - ### ####
Email
Department/School
Preferred Date for the Program Preferred Date for the Program / MM / DD YYYY
Preferred Time for the Program Preferred Time for the Program : HH MM AM/PM
Duration of the Program (in minutes)
Alternative Dates/Times
Estimated Number of Attendees
Program Location on Chicago Campus

Street Address and Room Number on Chicago Campus
Please describe the type of program that you are requesting (including the overall aim and specific goals).
How will you be marketing the program and/or ensure adequate attendance?
Other comments/questions?