UCS

Workshop and Group Interest Form

      
  
  Male    Female   

Contacting Me

I give permission for UCS to contact me or leave a message by the following means. I am aware that information exchanged over a cell phone and email could be intercepted by an outside party

Okay to call or leave a message if I am unavailable at:

Cell:    Residential:

Work:    Other:

(Please list in order of preference)

1)

2)

3)

If your schedule doesn't fit with these specific group dates/times, would you then be interested in a general counseling support group?

Yes    No

Monday:   Tuesday:   Wednesday:

Thursday:   Friday:

(Check all that apply)

Brochure Campus Fair Counseling Services Class Presentation

Daily Sundial Faculty Flyer/Mailer Friend Website

Other: