Education Request Form

I would like for you to present to my group/students/staff about the issues regarding sexual assault and/or dating violence. Scheduling is first come first serve, so please schedule workshops at least three weeks in advance to insure our availability. You may schedule workshops by phone by contacting Meg McIntyre at (216) 619-6194 ext. 114.

Contact Information

Name *

Organization

Daytime Phone *

Evening Phone

Email Address *

Presentation Location

Room Number

Directions and Parking

Check in at the main office

I have access to a VCR

Additional Information

Topics to Cover

Date and Acquaintance Rape

Sexual Harassment

Role of Alcohol and Drugs and Sexual Assault

Sexual Assault on the College Campus

Ways to be Safer

Other

Participants

Number of Participants

Participant Ages
10 and under

11 to 18

19 to 25

26 to 40

41 and over

Requested Date and Time

First Choice
Date: Time:

Second Choice
Date: Time:

Third Choice
Date: Time: