Boonshoft School of Medicine, Wright State University, Dayton, Ohio

Student to Student: Request a Program

Instructions: Due to the popularity of the Student to Student programs, please submit this request form well in advance to schedule the presentation and time of your choice. We are full-time medical students so talks can only be given as our schedules permit during the academic year, from late August to the beginning of May. Please allow at least two weeks' notice.

Today's Date:
School:
Address:
City:
ZIP:
Contact:
Title:
Day Phone:
Eve. Phone:
E-mail:

Talk #1

Which talk would you like presented?

Grade Level: Number of Students:

Preferred Date: Time:

Special consideratiions, if any:

Talk #2

Which talk would you like presented?

Grade Level: Number of Students:

Preferred Date: Time:

Special consideratiions, if any:

Talk #3

Which talk would you like presented?

Grade Level: Number of Students:

Preferred Date: Time:

Special consideratiions, if any:

Additional talks: (Please provide the same information as above or submit an additional form.)

Comments:

Student to Student: Request a Program

Thank you!