Outreach and Education Request Form

This is a brief description about the form below. Complete the form to request a workshop, presentation, or media interview.

Information Name of Requestor: Format: Full Name Email (Required) Format: jane.doe@utrgv.edu Phone Number: Format: (956) 000-0000 UTRGV Department:

Request Type: (Required) Training
Speaker/Presenter

Date of Event: (Required) Format: mm/dd/yyyy Time of event: (Required) Format: hh:mm am/pm

Delivery Method: (Required) Online
In person

Location: (Required) Format: (If online, enter if Zoom, MS Teams, etc.). If in person, provide building, room number, etc.

Audience (Required) (Check all that apply) Students
Faculty
Staff
Non-campus community

Purpose of event: (Required)

Office of Emergency Management