CAPS Outreach Request Form
Contact Information
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Name *
Phone Number *
Email Address *
UVa Affiliation *
Department/Res Hall/Group/Organization Name *
Programming Description
Type of Program
Topic Requested *
Preferred Presenter(s)
Audience *
Who will we be speaking to? Please select all that apply.
Expected Number of Participants *
Location for Outreach Program *
Scheduling
Please specify duration of program -- approximately how long would you like the provided programming to be, in hours and minutes. Please provide two or three options for the time and date.
Duration *
Preferred Dates/Times of Program, Option 1 *
GG
/
AA
/
YYYY
Saat
:
Preferred Dates/Times of Program, Option 2
GG
/
AA
/
YYYY
Saat
:
Preferred Dates/Times of Program, Option 3
GG
/
AA
/
YYYY
Saat
:
Technology/Materials Availability
Technology/Materials Available and Provided
Please check all that apply.
Other Information
Please provide any additional information about the topic, audience, department, level of training, cultural considerations, or other general preferences that will assist us in better tailoring the program to the group’s needs.
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