FOR OFFICE USE ONLY
Date Form Submitted:
DIVISION OF STUDENT ENGAGEMENT
Please submit at least ONE WEEK in advance. Type or print clearly in ink. See instructions on reverse side.
Name of Group, Department, or Individual
Bldg. & Dept or
Contact Information Home Address Work Phone
Open to non-campus public?
SET-UP REQUESTED: SERVICES REQUESTED
Use of Chairs: How many?
Use of Tables: How many?
Use of Podium: Yes No *Security Services?
PA System? Yes No Bowling Center?
Yes No Game Room?
Projection Screen? Yes No (*Note: Campus Police is mandatory for after hour activities)
Note: Decorating is to be done on the day of the event.
I understand that requests are not
approved unless all fees are paid and this form has been signed by the Director of Student Engagement.
I understand that all requests are approved in accordance with Coahoma Community College’s regulations regarding the usage of
facilities and are subject to cancellation if conditions make it necessary. I understand that faculty advisors, sponsoring departments, and/
or requesting groups will be responsible for their group’s activities and conduct during the function and may be required to pay for repair
or replacement of damaged areas or items. I understand that usage fees are payable in advance. The Abuse of regulations may result in
restricted or withdrawn privileges.
Faculty Advisor (College Activity) Date Coordinator of Student Activities Date
Organization Representative Date Director of Campus Safety Date
Director or Assistant Director of Student Engagement