Program Request Form

Please place your request at least 72 hours prior to the scheduled event. NOTE that submitting this form is not a guarantee that we can accommodate your program. Please make sure that the contact information you provide is correct as this is how we will get in contact with you.

Fields marked with * are required.

Type of Program Requesting (not limited to the following): Alcohol/Drug Awareness
DUI (Drunk goggles simulation when possible)
Personal Safety
SAFE (1-2 hours self defense program *WOMEN ONLY*)
RAD (12 hour self defense program *WOMEN ONLY*)
Theft Prevention
Residence Hall Safety
Sexual Assault
Greek Safety
Social Networking Safety
Work Place Violence
Active Shooter
Other (Please specify below)
*
*
*
Contact Information
*
*
*
  999-999-9999
*
  test@example.com