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:
- -
Time:
: to to
Location:

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)

Date

Contact Info

LGBT Outreach & Services 245 Snell Hall, 541-737-6342 LGBT.Services@oregonstate.edu
Copyright ©  2014 Oregon State University
Disclaimer