EOPS/CARE Presentation Request Form

EOPS/CARE Presentation Request Form

Thank you for showing interest in our Mt. SAC's EOPS/CARE Program.

Please complete the form below to request an EOPS/CARE presentation for your class, student organization, or other events.

Our EOPS/CARE presentation topics include:

Please allow two (2) weeks advance notice for speaker requests when possible.

A representative from our EOPS program will contact you within three (3) business days of receiving this request.

Please Note: If you need confirmation before three (3) business days, please complete this form AND call our office at (909) 274-4500.

If you have any questions, please reach out to our EOPS/CARE Program Specialist, Kaitlyn Yrineo, at kyrineo@mtsac.edu or (909) 274-4500.

First Name*

Last Name*

Relationship to Mt. SAC*

Select or enter value

Requestor's Contact Information

What is your title/role?*

What program / department are you representing?*

What is your Mt. SAC staff email address?*

What is your email address? *

What is the best phone number to reach you at?*

Phone

What is the name of your High School? *

What organization are you representing?*

What is the number of your organization?*

Phone

What is your High School's number?*

Phone

Please provide the address of your High School.*

Please provide the address of where you are requesting the presentation*

Please identify the location where you are requesting for EOPS to present.*

Select or enter value

What is the name of the class?*

Please provide the building and classroom location.*

Please provide the name of the event.*

What date are you requesting the presentation?*

Please provide the time you would like for us to present.*

Length of the presentation*

Expected number of attendees*

Location of the presentation*

Additional Comments

Send me a copy of my responses