DEPARTMENT OF ATHLETICS
MULTI-PURPOSE REQUEST FORM

Phone Number (required)


Cell Phone Number (Cell)


Contact Email (required):



Campus Box Number/Street Address


City, State, Zip

Please select the day (s) you would like to use the dance room (Primary)

Please select the day (s) you would like to use the dance room (Secondary)

What is the Starting Date

What is the Ending Date


Approximate Number of Participants


Who will be offering/teaching the course

What are the instructors credentials and experience

Do you offer the course elsewhere? If yes (please specify where)


Are you charging for your services?


If yes, how much?


Is this your normal fee?


If no, what do you charge elsewhere?

Additional Comments

No classes will be scheduled or run in the Kneller Center without approval from the Athletic Department