Outreach Program Request
If you would like CMU CAPS to present an outreach program, please complete and submit the form below. Once the request is received, a staff member will contact you to discuss the details of your request. Please provide at least two weeks' notice before an outreach event. Thank you!
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Email *
 Name of your Department/Program/Organization: *
 Your Name: *
Include first and last name
 Position/Title/Role: *
 Your Email Address: *
 Your Phone Number:
Include area code, e.g., 412-123-1236
 Date(s) of Event:
MM/DD/YYYY
 Day of Event Contact: Name, Phone, Email
Same as person listed above? Type SAME
 Start and End Time for Event:
Let us know if time is flexible.
Location of Event:
Address, building, and room number (if known)
 Tell us about your event and what you would like from us:
Please give us as many details as you can about your event.
 Anticipated Number and Description of Attendees:
For example, "25  Student Members" or "15 Staff Members from Tepper"
By checking this box I recognize and understand that my email address is provided solely for inquiries about CAPS and its outreach functions. I understand that this is not a form of contact for clinical treatment or help in emergency. If I do need clinical treatment I must call or visit the counseling center during office hours. If this is an emergency, please call 911 or CMU Campus Police at 412-268-2323. *
Required
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