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Student Success Programs Outreach/Presentation Request
Date of Request
Department/Organization
Contact Name
Contact Email
Presentation Topic
Date(s) of Presentation (MM/DD/YYYY)
Time of Presentation (Ex: 10:00 am)
Length of Presentation (Ex: 45 mins)
Location of Presentation
Type of Outreach/Presentation
Discuss objectives/purpose of the Student Success Programs
Other (please specify below)
If "other" for the previous question, please explain
Estimated Audience Size
Audio/Visual Equipment Provided
Yes
No
Special Characteristics/Needs of Audience
Special Requests for Program (i.e., facilitator background and/or demographics)
Facilitator(s)
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