The Center Education Training and Workshop Request Form

1. Please complete the following form:

*This is not a contract and serves as a basic request that will be reviewed and responded to within 7 business days.

*4-6 weeks advance notice is preferred when requesting a program or educational assistance.

*In order to effectively and efficiently fill your request, any member of The Center staff may conduct your training/workshop/meeting.

*If you have any questions, please contact us at cmep@nyu.edu.

1. Title of proposed session or topic area:

Title of proposed session or topic area:

2. Program Type:

Program Type: Center 101 (overview of Center programs/goals)

Workshop (short interactive session)

Training (longer interactive session around specific area, 90+ minutes)

Presentation/guest lecture (10-40 minutes on specific topic of expertise)

Other (please specify)

3. Date & Time

	MM		DD		YYYY	HH		MM	AM/PM
1st Choice:	Date & Time 1st Choice: Month	/	Day	/	Year	Hour	:	Minute	AM or PM
2nd Choice:	2nd Choice: Month	/	Day	/	Year	Hour	:	Minute	AM or PM
3rd Choice:	3rd Choice: Month	/	Day	/	Year	Hour	:	Minute	AM or PM

4. Duration of training/workshop (i.e. 75 minutes):

Duration of training/workshop (i.e. 75 minutes):

5. Target Audience

Target Audience

6. Learning goals/outcomes and/or subject area:

Learning goals/outcomes and/or subject area:

7. Desired outcomes/method of assessment:

Desired outcomes/method of assessment:

8. Sponsoring organization(s), department, or class (please provide what class):

Sponsoring organization(s), department, or class (please provide what class):

9. Budget for program (i.e. food, copies, etc.)

Budget for program (i.e. food, copies, etc.)

10. Expected Attendance:

Expected Attendance:

11. Location:

Location:

12. Special needs/considerations:

Special needs/considerations:

13. Contact person and information:

Contact person and information: Name:
Department:
Position:
Email Address:
Phone Number: