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About-Face Presentations - Request Form

I. Basic Information

First Name (required)

Last Name (required)

E-mail Address (required)

Street Address (required)

City (required)

State/Province (required)

Zip (required)

Country (required)

Phone Number (required)

School/Organization (required)

Presentation requested

Desired presentation date

Date today

II. Presentation Information

Reason for a presentation (fits into class curriculum, body image issues arising in individuals)

Anything specific you would like to see addressed in this presentation?

How did you hear of these presentations?

III. Participant Information

How many anticipated to attend?

Age range

Gender

Race/Ethnicity

How familiar are the participants with the content matter?

Anything else you would like to share about the participants?


 



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