56 MDG Health Promotion Services Request Form Survey

Thank you for interest in health promotion and human performance! Please submit your request with 3-4 weeks' notice and have an audience of five participants or more. You will be contacted by a Health Promotion staff member to confirm the service. We will try our best to facilitate everyone but understand that specialists are also limited.

DISCLAIMER: These services normally take the form of one-time workshops, presentations, events and classes. They are not intended to be multi-event presentations. Examples of what we have done in the past have been (but not limited to) nutrition for weight management, stress relief techniques, goal setting workshops, being resilient to failure, and exercise for injury prevention.

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* 1. Personal Information

Name (Last, First)

Rank

Squadron

Building Number

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* 2. Contact Information

Phone Number

Email Address

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* 3. Estimated number of attendees (at least five or more are needed to utilize service)

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* 4. Topic of Concern (Select One or More)

Nutrition

Tobacco-Free Living

Sleep Optimization

Physical Fitness

Stress Management

Other (please specify)

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* 5. Preferred day of the week to receive service (pick one or many)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

56 MDG Health Promotion Services Request Form

Requester

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* 1. Personal Information

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* 2. Contact Information

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* 3. Estimated number of attendees (at least five or more are needed to utilize service)

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* 4. Topic of Concern (Select One or More)

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* 5. Preferred day of the week to receive service (pick one or many)

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* 6. Preferred time to receive service (start-stop time)

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* 7. Is there anything else you would like us to know before contacting you of your request?