Diversity Education Request

Requestor

Name *

Pronoun *

he/him/his/his/himself

she/her/her/hers/herself

they/them/their/theirs/themselves

ze/hir/hir/hirs/hirself

E-mail *

Contact Number *

Name of department, office, organization or group

About the Experience

Topic(s) request

Anticipated # of attendees

Intended audience (specify % of students, faculty, staff, community members, etc.)

Preferred date(s) and time of day

Preferred time frame for experience

Other Information

Expected outcomes of the experience

Frequency of experience (select one)

One time

Multiple experiences

Is this the first diversity education experience for your organization or department? (select one)

Yes

Leave this field blank