ࡱ> OQNc  bjbj 2@ua\ua\\qNN,#0ffff|> "#$#$#$#$#$#$#$$'H#H#f|]#iii"f|r"i"#iiL6|,\^"s#0#, (/ (v (V iH#H## (N> : Specify Program or Service you are Requesting: List objectives for requested service or program: Program Date: Program Location: Program Start Time: Number of Participants Expected to Attend: Program Length: Date of Request : Requesters Name: Position/Title: Department: Phone Number: Fax: Mailing Address: Special Instructions:Additional Needs: Service Providers Name(s): Date of Presentation: Type of Program or Service Provided  Class Presentation ______Orientation _______Workshop _______RA Training _______ Group Facilitation ______Consultation _______Info Table _______Other/specify _______ Participants Fill in number and type(s):ϰϲʹٷ students __________ϰϲʹٷ Staff __________ϰϲʹٷ Faculty ________Other/specify _________ I conducted an evaluation of this session YesNoNA To be filled out by person requesting program 02-16-18/bm Please mail completed requests forms to: Outreach Coordinator Counseling Center UN220 or email to:  HYPERLINK "mailto:b.menapace@csuohio.edu" b.menapace@csuohio.edu Please submit outreach requests at least 30 days prior to the program date To be completed by the staff who does the outreach Program #$-./1237cdfgjkwxz{||xnnݖnnfh%hEu: *hm8hEu:hGf *hm8hGf: *hm8h#}: hGfCJ hwb: hGf: *hhGf:h5 hvCJ hrCJ h5CJ h5: *hh5:hEu h28: hs+: hEu: *hhh: *hhEu: *hh#}:(23ghijkkd$$IflK-l-    6`0l-64 la$&`#$/Ifgdvjk{$&`#$/Ifgd?-kkd$$Iflh-l-   6`0l-64 lan\$&`#$/Ifgd?-$&`#$/Ifgd28~kd`$$Ifl0g-     6`0l-64 laweeO$&`#$/If^gd$$&`#$/Ifgd?-kd$$Ifl40g-   6`0l-64 laf4p     ! # $ % / 0 2 3 4 @ A B C F G I J K Z [ ] ^ _ s t u v h}CJ hq: *h@h}: hNj: *h$_Kh}:h} h}:CJ$ hK: h2\: h}: *hm8h}: h7: *hEuhEu: h,: *hm8h,: hwb: hEu: *hm8hEu:hEu/ $ P>,$&`#$/Ifgdv$&`#$/Ifgd?-kd$$Ifl4Fg- QH   6`0l-6    4 laf4p$ % 3 }k$&`#$/Ifgdvkd$$Ifl0g-   6`0l-64 laytxy3 4 C J q$&`#$/Ifgd?-$&`#$/Ifgdvikd$$Ifl-l-   6`0l-64 laJ K ^ p$&`#$/Ifgdv|kd$$Ifl0~-   6`0l-64 la^ _ u $&`#$/Ifgd?-ikdp$$Ifl-l-   6`0l-64 lau v $&`#$/Ifgd?-ikd$$Ifl-l-   6`0l-64 la $&`#$/Ifgd}ikd$$Ifl-l-   6`0l-64 la    " ) 6 = > ? 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