Facility Reservation Request

Your name*

First Last

Department

University email*

Campus phone

Will you be present during the event?*

Name of day-of contact

First Last

Email for day-of contact

Briefly describe your event and how you will be using the space.*

Desired date and time of event (Please provide multiple options, if possible.)*

Expected number of participants

Educational/professional level of participants

If you checked "Other," please describe.

Check box to request the following:

Number of conference rooms requested

Please enter a number less than or equal to 2.

Number of exam rooms requested

Please enter a number less than or equal to 20.

Will you be serving food or drinks?*

Will your event require any of the following?

Detailed description of any equipment or supplies that you will need and instructions for set-up:

Number of Standardized Patients needed

SP Demographics:

Please list any demographic requirements or exclusionary characteristics(include age range, gender, and exclusionary characteristics, if applicable)

Worktags

If your department is being billed for SPs, please include worktags so that your account can be charged directly

Questions or comments