EIU - Health Education Resource Center

Your Questions, Real Answers


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	Health Education Resource Center Eastern Illinois University 600 Lincoln Avenue Charleston, IL 61920 Phone: (217) 581-7786 Fax: (217) 581-8330 Email: herc@eiu.edu

H.E.R.C. Program Request Form

Note: Please place requests two weeks in advance to ensure availability of your program.

Personal Information
First Name:
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Department / Organization:
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Email Address:
Best Way to be Reached:	Phone Email

Presentation Information
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Presentation Style:	Lecture Panel Discussion Other:
Technology Available: (Computer and Projector)	Yes No
Help with Promotion:	Yes No

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