ADMYRE: Advocating for My Relationships College Edition Program Request

ADMYRE: Advocating for My Relationships College Edition Program Request

Contact Information

This section asks for contact information that will be used in correspondence regarding this request. Any additional contacts, such as day-of staff for an event, should be entered into the "Additional Comments" box at the end of this form.

Contact Name*

Contact Email*

Audience Information

This section asks for information about who will be participating in or attending this event, presentation, program, or training. The information you provide here will help us to better tailor our content to your group.

Group Type*

Select or enter value

What is the name of the group you are submitting for?*

Please write a specific name (e.g. Class - Engl 250, Section 12, Delta Delta Delta, Starbuck House, Pride Alliance, etc.)

Number of participants*

What accomodations, if any, do you need from us?

Accommodations are tools or resources to improve your ability to participate and be present, such as captioned media or meeting locations that are accessible without stairs. We are happy to work with you to find ways to better meet your access needs.

Presentation Details

If you have multiple dates available, please email hluhrich@iastate.edu to schedule.

What version of the ADMYRE program would you like?

Select or enter value

What are the meeting times and dates available to run the program?*

Where will the presentation take place?*

Please note: The ADMYRE program requires a large room to run the story simulation.

Please include the address and room number if applicable.

Will a projector be available for the PIAL staff to use?*

Yes

Will internet be available?*

Yes

Are there dynamics and/or life experiences in any of the groups that PIAL staff should be aware of?*

This can include any partcitipant recent experiences of sensitive topics that may invoke an emotional response. If yes, please explain below. If no, please indicate NA.

What additional information would you like to share?

(i.e. number of staff available to help)

How did you hear about Advocating for My Relationships?

Did someone refer you to Parenting: It's a Life?*

Yes

Who referred you?

Thank you!

Thanks for choosing Parenting: It's a Life! We look forward to visiting you soon.

You have the option to send yourself a copy of your form's response (below this message) which will include a link to request our PIAL curriculum.

Send me a copy of my responses

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