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)




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

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