Oregon State University

Safe Space | Pride Panel Request Form

I. Your Contact Information

First Name:
Last Name:

E-mail address:
Phone number

II. Class/Event Information

Is this request for a Pride Panel or Safe Space Presentation? Pride PanelSafe Space

Class or Event Title

Date of Class/Event:
- -
: to to

For this class or event, Are you Instructor, TA, or Student?

Topic or Theme of Class/Event

How many people will be attending?

What do you want Panelists to share with your students?

Panelist Names (for LGBT Services Use only)


Contact Info

LGBT Outreach & Services 245 Snell Hall, 541-737-6342 LGBT.Services@oregonstate.edu
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