Columbia University Health Services

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Your Information

Name*

Title

Organization*

Campus Email*

Campus Telephone*

Event Time and Place

Note: Requests for Stressbusters must be submitted at least two weeks in advance of your event date.

Date*  

Time*

Location*

Expected Number of Attendees*

1-25 26-50 51-75 75+

Type of Event*

Residence Hall Floor Event

Student Organization

Information Health Fair

CU Staff Event

Other

If other, please explain

Additional Comments

Disclaimer: Please note that this page is not secure and if an individual has concerns about the sensitivity of the information being transmitted he/she should contact the sponsoring area or department of Health Services to discuss alternative means of transmitting data.