OUTREACH REQUEST FORM


While filling out the request form, please note the following information:

  1. In order to do our best, we ask that requests for outreach be made at least two weeks in advance of the preferred presentation date. You should expect to hear back from the OSARP within one week of submitting this form.
  2. If there is a change in your venue, please notify us within 48 hours so that we may adjust plans accordingly.
  3. If you have additional questions, please contact Lauren Ellis, Assistant Director of Restorative Practices.

Contact Information

Date of Request: Pick a date Click to select a date
Contact Name:
Contact Position/Role/Title:
Mailing Address:
Phone #: --
Alternate Phone #: --
Fax #: --
Email:
Website Address:
Preferred Contact Method:
Best Time to Contact:

Organization Information

Organization Name:
Organization Type:
Type of Audience: (e.g., Community Members, Club Members, Classroom, Graduate Students, Mixed Students, Undergraduate Students, Freshman, Sophomores, Juniors, Seniors, etc.)
Audience Need Fulfillment/Outcome Anticipated:
Other Affiliates/Community Partners/Departments Involved or Invited:

Presentation Information

 
1st Choice
2nd Choice
3rd Choice
Date:
Time:
Setup Time: (10 minute min.)
If Other, please specify:
Presentation Duration: (15 minute min.)
If Other, please specify:
Audience Anticipated:
If Other, please specify:
Layout of Location:
If Other, please specify:
Presentation Type:
If Other, please specify:
Technology Available: Projector
Microphone
Computer
TV/DVD player
Sound System
Whiteboard
Other:
Topic(s) Requested:
Previous Presentations by our office?

If Yes, Topic(s) Covered:

Date of Last Presentation(s): Pick a date Click for date

JMU Passport Event:

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