Video Room Number:

Your name:

Your email address:

Your phone number:

Choose the type of the event:
Credit Non Credit Seminar Meeting Faculty/Staff Training

If a credit course, select the number of credits earned for this course:
None 1 2 3 4 5 6 7 8 9 10

Event or Program name (if course, include Department and Course Number):

Name of the Instructor or Facilitator:

Date(s) of the event (if it is a regular course, enter the start date and end date):

Or, if your course occurs on a weekly basis, check the days of the week on which it meets:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Starting time(s):

Ending time(s):

If a regular course, enter any exception dates (holidays, etc.):

List any special arrangements or make any other comments:

Host site of the course:

Approved by:

Site #2:

Approved by:

Site #3:

Approved by:

Site #4:

Approved by:

Site #5:

Approved by: