Director or Assistant Director of Student Engagement Date
Coahoma Community College
Division of Student Engagement
Office use only!
Student Activities Form
The college reserves the right to cancel a reservation for special and/or unforeseen circumstances, although every
effort will be made to honor scheduling.
A permit will be issued when approval for the event is granted.
To avoid any delays in processing and receiving approval for your program, complete each line as
Incomplete forms will not be processed.
All forms must be submitted to the Division of Student Engagement at least two weeks prior to the event. Any
forms submitted after this time may not be scheduled due to improper notice.
ACTIVITIES ARE NOT TO BE HELD DURING THE LAST TWO WEEKS OF A SEMESTER!
Name of Organization requesting space/activity Name of person requesting space/activity
Requestor’s phone number email address
Advisor’s Name extension email address
Name of facility requested (1
Any room reservation that exceeds the normal business or operating hours of the facility will require Coahoma Community College
Campus Police present.
Date of event/ activity/solicitation (1
Event starting time Event ending time
The event start time and end time should include time to set up and breakdown the event. Decorating will only be allowed the day of
the event unless otherwise authorized with facility director.
Expected Attendance (Number) Expected Audience
Type of event:
other (please describe)
Will money be collected for this event?
Who will collect the revenue?
Will campus police be needed for this event?
Unit Dean or Director Date Club/Organization Advisor Date
Student Activities Coordinator Date
Director of Campus Safety Date
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