*Required Fields

*Activity Name:

*Date: January February March April May June July August September October November December/ 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31/ 2005 2006    

 *Time:  From: 01 02 03 04 05 06 07 08 09 10 11 12: 00 15 30 45   AM   PM

  *Time:      To: 01 02 03 04 05 06 07 08 09 10 11 12:  00 15 30 45  AM   PM

*Contact Name:

*Contact Phone Number: ()    E-Mail Address:

*Contact Address:        Fax: 

 Instructors: 

*Estimated Number of Participants:  

*Requested Room Arrangement.  Please select one:

Audio/Visual Requests

Equipment

VCR
Overhead-Projector
CD/Audiotape Player
Visual Presenter (Elmo)
Microphone:  How many?
            Corded
            Wireless
                Lapel
                Handheld
Video projector for a computer you are bringing:
    PC
    Mac
DVD Player

Internet Access

Particular software in computer lab?   Specify:

Will you be having food catered?    Yes   No   

            Name of Caterer: 

Do you have a particular room request?

Special requests regarding room arrangements: