Student Life and Services

Activity / Event Request Form
(Revised 05/17/16)

*A minimum of two weeks notice is required for each event that is requested. A separate form must be submitted for each event.

Step 1: Complete and submit this form to the Office of Student Life and Services (attach and submit budget and flyer for event with form).
Step 2: Receive a written decision regarding this activity/event request from the Associate Vice President of Student Affairs – Student Life and
Services and/or designee PRIOR to planning and/or publicizing event.

Title of Event:
Event Date:
Type of Event: / c Social c Educational
c Fundraiser c Other ______
Description of Event:: / The current members of the chapter and alumni are invited to celebrate Charter Day for the chapter. There will be a “tea” for everyone to participate in. With a slightly formal program during the time frame.
Name of Club/Organization:
Name of Advisor:
Advisor’s Cell Phone:
Advisor’s E-Mail:
Location: / cAuditorium (Building 46) c Gym
c Auditorium Lobby (Building 46) cPlaza (Connecticut Ave)
cWindow’s Lounge c Dennard Plaza
c Building 41, A-03 cStudent Lounge (38/B-Level)
cBuilding 44, A-03 cOther ______
c Student Center – Specify Room ______
Setup Style: / cClassroom Style cRound Style
c Theatre Style A cTheatre Style B
c Instructional Theatre Style c Interview Style
Time Requesting Room to be Open: / 6pm
Event Start Time: / 7pm
Event Ending Time: / 10pm
Publicity Request(s): /
cUDC Online Calendar c Flyer (Please attach.)
c UDC TV Monitors cOther: ______
c Twitter
cCampus Photographer
Technical Need(s): /
cMicrophone cLCD Projector
c Podium c Other: ______
Miscellaneous Need(s): / cTables c Round # ______c Square # ______
c Other: ______
Other: / Estimated Number of Attendees: ______
Will there be an admission fee? £ Yes Amount: $ ______£ No
Is the event open to the public? £ Yes £ No
Will there be any food? £ Yes Caterer: ______£ No
Will there be music? £ Yes £ No
Will there be any entertainers? £ Yes £ No
Additional Comments:
By the signature(s) below, the representative(s) submitting this request certify that the information provided on this form is accurate and correct to the best of my knowledge. By submission of this form, the representative(s) acknowledge and understand that this is a request and does NOT imply or constitute a contract or approval.
Printed Name of Person Submitting Request:
Signature: / Date:
Title/Role of Person Submitting Request: / c Student c Advisor c Other ______
Email Address of Person Submitting Request:
Phone Number of Person Submitting Request:
Club/Organization (President) Name:
Club/Organization (President) Signature: / Date:
Club/Organization Advisor Name:
Club/Organization Advisor Signature: / Date:
Club/Organization Advisor Email Address:
Club/Organization Advisor Phone Number:

For Office Use Only

SLS Specialist Signature Printed Name Date
Club/Organization Status for this Term ______/ Year: ______: £ Active £ Inactive
Comments: /
£ Yes £ No £ N/A
AVP Student Affairs Signature Printed Name Date
£ Yes £ No £ N/A
Space Reservations Signature Printed Name Date
£ Yes £ No £ N/A
Facility Coordinator of Building/Space Requested Signature Printed Name Date
£ Yes £ No £ N/A
Campus Safety Signature Printed Name Date
Comments: /
£ Yes £ No £ N/A
Student Accounts Signature Printed Name Date
Comments: /
£ Yes £ No £ N/A
Food Services/Contractor Signature Printed Name Date
Comments: /
£ Yes £ No £ N/A

08/21/12 Draft Page 3 of 3