1. Please provide the following contact information:                                

Name
Title
Work Phone
Home Phone
E-mail

2. Select the workshop you would like to request. Choose one of the following workshops:

Be safe. Be smart. Be aware. Body Image and Attitudes Body Reflections Boozin' and Choozin' Let's Talk About Sex Men & Women Sharing Rest and Relaxation Roommate Game Rubber to the Rescue Sex Connection/Jeopardy Shots and Ladders Specialized Workshop Study Break Take A Walk in My Shoes UMaine 101 Up in Smoke

3. Target Group:

4. Where would you like to host the workshop (location & building)?

5. Because Peer Educators are students, with busy schedules, we ask that you supply three possible dates so that we can do our best to prepare the workshop.  

Enter your first choice date and time :

    date: -- mm/dd/yy    Time : -- hh:mm am/pm

Enter your second choice date and time:

     date: -- mm/dd/yy     Time : -- hh:mm am/pm

Enter your final choice date and time :

     date: -- mm/dd/yy     Time : -- hh:mm am/pm

6. Do you have any special requests ?

7. A Peer Educator will contact you within TWO business days from our Monday afternoon meeting to confirm your workshop. Thank you!