Health Education and Promotion Activity Request Form

Please use the form below to request a FREE interactive session from Health Education and Promotion. All fields are required. Thanks, and we'll be in touch shortly.

*Please note that Health Education and Promotion requires at least 10 business days in advance notice in order to ensure that we are available to facilitate your program at the preferred date and time.

**Please also note that even with advanced notice, we do not guarantee that we will be available for your first preferred date and time so please have an alternate in mind.

Contact Information
Requestor Name Requestor Name * First Last
Email *
Organization/College
Campus? *
Phone Phone - ### - ### ####
Which Activity Would You Like
If you would like to learn more about our different programs and activities please visit http://healthed.info.yorku.ca/whatweoffer/ *

Which Activity Would You Like
If you would like to learn more about our different programs and activities please visit http://healthed.info.yorku.ca/whatweoffer/ One-on-One Meeting with Professional Health Educator Fatal Vision Goggles Mindful Jeopardy Plan Your Night! Sex on the Couch Ways of Wellbeing Healthy Plate Mind Your Method General Cannabis Tabling

If you would like to learn more about our different programs and activities please visit http://healthed.info.yorku.ca/whatweoffer/
Activity Information
First Proposed Date First Proposed Date * / MM / DD YYYY
Second Proposed Date Second Proposed Date * / MM / DD YYYY

Even with one week's notice your first preferred date may not be available. Please choose an alternate date.
Start Time Start Time * : HH MM AM/PM
End Time End Time * : HH MM AM/PM
Expected Number of Participants *
Where Will the Activity be Taking Place?

please provide any parking/entrance/special instructions
On the Day of the Presentation...

To ensure the activity runs seamlessly on the date of the event.
Name Name * First Last
Who will be meeting the team before the event
Phone Phone * - ### - ### ####

Of the person meeting the team for the event
Building Entrance

At which building entrance will the Health Ed team be met
Meeting Time Meeting Time : HH MM AM/PM

We suggest a meeting up with the Health Ed team at least 20 minutes before the proposed event start time for set up.

Health Education and Promotion Activity Request Form

Health Education and Promotion Activity Request Form

Contact Information

Activity Information

On the Day of the Presentation...