University Session Request

University Name:

Facilitator Information

Lead facilitator name

Lead facilitator email(Required)

Co-Facilitator (if applicable):

Click the + icon to add additional facilitators.

Name

Upload photo(s) of the University facilitator(s).

Drop files here or

Max. file size: 256 MB.

Upload your University's logo.

Max. file size: 256 MB.

Student(s) assisting with session (if applicable):

Click the + icon to add additional students.

Name

Session Information

Session date & time request:(Required)

e.g. Every Tuesday 4 pm ET. Please provide up to 3 available options using Eastern Time Zone. Click the + icon to add additional options.

Date

Time

Start Date(Required)

End Date(Required)

Dates you will not be having a session:

For example, Spring break dates or Winter break dates.

Session Title(Required)

e.g. Think Positive!

Session Description(Required)

This is a short 2–4-line description about the session you will be facilitating. Please keep this aphasia friendly! Example description: “Join Dr. Lea Kaploun and the Nova students for this weekly session all about finding the positive in each and every day of your aphasia journey. Living with aphasia can reveal your inner spark of strengths and talents you never thought you had. Come join our conversation, where we learn from each other, lean on each other, and share our gifts!”

Will your students need an orientation before starting Virtual Connections sessions this semester?

Yes

Orientation date and time

Please provide a list of possible dates/times (with time zone) that you and the students would be available for the orientation. Student orientations typically last 30-45 minutes. Following submission of this form, a member of our team will reach out to you for scheduling.