DEPARTMENT OF STUDENT SUCCESS SERVICES
STUDENT ACTIVITY REQUEST FORM
Date Submitted: _____________ Name of Club/ Organization: ______________________________
Submitted by: ___________________________________ Title: _______________________________
Date of Activity: _____________ Time: __________ Location of Activity: _____________________
Title of Activity: _______________________________________________________________________
Contact Person: _____________________________ Phone Number: ___________________________
Nature of Activity: ______________________________________________________________________
Is there a fee to participate in this activity? ______ Yes _______ No
If yes, what will the funds raised go toward: _________________________________________________
Number of members expected to attend activity: _____________________________________________
The activity is open to (check all that apply):
______ Members Only _____Student Body _____ Faculty/ Staff _____ General Public
Number of students/ faculty/ staff/ general public expected to attend activity: _____________________
Please list the sponsor(s) for the planned activity: ____________________________________________
Please indicate the avenues used to promote this activity:
_______ Chalk _______ Flyers ________ NewStar
_______ Banners ________ Invitations ________ Other Campus Media
Club/Organization President: _________________________________Date: ______________________
Club/Organization Sponsor: __________________________________ Date: ______________________
Coordinator Student Activities &
Conduct Administration _____________________________________ Date:_______________________
OR
Dean of Student Success Services: _____________________________ Date: _____________________
