Request form for event or presentation

Current Date «

Requested By (e.g. Dr. John Jones) «

School (if not Dental)

Department «

Division (if applicable)

Contact Phone number «

Contact Email Address «

Presenter name if different from above

Course name and ID if applicable (e.g. REST 521 - Dental Implant) «

Lecture Topic &/or Title «

Would you like this event captured using Mediasite? «

Please fill out Mediasite Reservation Form, Link Provided in Comfirmation Page After This Form is Submitted

Yes

Time e.g. 8 - 10 AM «

Location (room) «

Video files associated with lecture? «

Yes

Using own Windows laptop?

Yes

Using own Mac laptop?

Yes

Special Instructions

Fields marked with "«" are required.