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Community Education Request Form

Contact Information

*First Name:
 
Middle Initial:

*Last Name:
 
*Organization Name:
 
*Phone Number:
 
*Email:
 

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Presentation(s) requested

*Requested Program Topic(s):
Select A.L.I.C.E R.A.D S.A.F.E K9 Alcohol awareness Drug Information and Safety Women’s Safety Drunk Driving LUPD general information Social media safety LUPD unplugged forum Concealed Carry Conflict Management Leadership 101 Fire Safety Domestic Violence The Law and You Other
If you selected other, please describe the type of programming you are interested in:

*Date requested:

*Time requested:
Select 8:00am 8:30am 9:00am 9:30am 10:00am 10:30am 11:00am 11:30am 12:00pm 12:30pm 1:00pm 1:30pm 2:00pm 2:30pm 3:00pm 3:30pm 4:00pm 4:30pm 5:00pm 5:30pm 6:00pm 6:30pm 7:00pm 7:30pm 8:00pm 8:30pm 9:00pm
*Length of presentation (i.e. 1 hour)?
 
*Location of presentation:

*Approx. # of attendees:
 

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Additional Comments:

Security Password (Please type the word ):

If you have questions or concerns you can contact Officer Claire Singleton at 815-836-5222 or singlecl@lewisu.edu. Share ➤