HPO Program Request Form

Thank you for requesting one of the HPO's interactive programs for your group, floor, or class. In order to process your request promptly, please complete this form with as much information as possible.

PLEASE NOTE THAT THE HPO REQUIRES AT LEAST TWO WEEKS NOTICE FOR ALL PROGRAM AND TABLING REQUESTS. This lead time allows us the opportunity to find facilitators who can accommodate the date(s) and time(s) you've requested. Please be aware that requests made with less than two weeks' notice are less likely to be fulfilled.

Upon receipt of this completed form, we will notify you no later than one week prior to your first choice date with an official response to your request.

Again, thank you for requesting the HPO!
EVENT HOST CONTACT INFORMATION: The Event Host will act as the liaison during the scheduling and preparation process. The Event Host should be present for the entire duration of the event and assist as needed.
EVENT DATE: To better meet your scheduling needs, please provide us with two dates during which your group is available. NOTE - dates should be a minimum of two weeks from today.
MM DD YYYY HH MMAM/PM
First Choice Date:
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Second Choice Date:
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EVENT LOCATION: Different programs require different venues. Health Leader Tablings require a space that fits a table/two chairs and is in a well-trafficked location. Dicey Decisions requires a classroom setting with a laptop connection and a projector.
PARTICIPANT DETAILS: So that we may better tailor our events to your group’s needs, please provide the following information. Due to the interactive nature of our events, we request that you ensure A MINIMUM OF 15 PARTICIPANTS.
PROGRAM MENU (please choose one program):
ADDITIONAL REQUEST INFORMATION/QUESTIONS:
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