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Brockport / Prevention and Outreach Services / Program Request Form

Program Request Form

Thank you for your interest in Prevention and Outreach Services programming. Please complete all required fields of the Program Request Form below. Within 48 hours, a Prevention and Outreach representative will be in touch to discuss your request and to begin the planning process.

As of January 2014, we have migrated our Program Request Form to myBrockport. 

Programs can be requested under "forms" on the Prevention and Outreach Services myBrockport page. You will need to login to myBrockport.


Please note that an RA or an RD are required to be present for the duration of your requested program AND all program request forms must be received at least 2 weeks prior to an event or program.

 If you have any questions, please contact Prevention and Outreach Services at (585) 395-5599 or the Center for Select Respect at (585) 395-5881. 

If the form fails to load here, you can go to the form.

Last Updated 9/16/15