Request for Health Promotion Presentation

Name:

Group or Organization Name:

Requested Date for presentation:

Requested Time:

Place:

Phone:

Email:

Topic:

Sexually Transmitted Infections Beginning an Exercise Program

Alcohol poisoning Exercise Basics

Alcohol/Substance Abuse Nutrition Basics

Binge Drinking Eating Disorders

Stress Management Body Image

Other (please specify)__________________

* Requests must be made at least 2 weeks before the presentation date.

Completed forms can be faxed to 266-4205, attention Health Education or attached in an email to Jodi Tate, Health Education G.A. at jodi.tate@usm.edu

For more information call Health Education at (601)-266-5266 or email Jodi Tate, Health Education G.A. at jodi.tate@usm.edu or Susan Dobson, USM Health Educator at susan.dobson@usm.edu