KSC Mentors in Violence Prevention Peer Education Program Request Form.
Questions marked by * are required.
1. Name of who will be hosting program: *
2. Host's email address: *
3. Program will take place in a:
  • Classroom
  • Res Hall
  • Other
4. Location details:
5. If Classroom, what is the course and is there a topical tie-in?
6. Choose a topic for your MVP program:
7. Notes on topic or other:
8. Choose a date or list possible dates for program:
9. Choose a time or range of times for program:
10. I will be able to provide:
  • Computer, Projector & Screen
11. Estimate of how many students who identify as non-binary will attend:
12. Estimate of how many students who identify as female will attend:
13. Estimate of how many students who identify as male will attend:
14. For Faculty Hosts: I agree that after I introduce the MVP Peer Educators I will leave the room so the program is truly peer education:
  • Yes
  • No
15. Other requests/comments/concerns: