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Activity Provider Request

* indicates a required field

Requester Info

Please provide your information so that we know who to contact with questions and confirmations. Please note that any ASL or CART request made with less than 72 hours notice cannot be guaranteed.

Requester First NameRequired *

Requester Last NameRequired *

Requester EmailRequired *

Accommodation Request

Type of AccommodationRequired *

Accommodation requested for:Required *

Student IDRequired *

First NameRequired *

Last NameRequired *

EmailRequired *

Activity TypeRequired *

Activity NameRequired *

Single Request or Recurring?Required *

Is this request for a single date/event or for ongoing recurring dates?

Activity DateRequired *

First Date of RequestRequired *

Last Date of RequestRequired *

Please select recurring days of the week:Required *

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Activity Start TimeRequired *

Activity End TimeRequired *

In person or online?Required *

Activity LocationRequired *

Please provide the Zoom link or physical address and room number/name. Special instructions can be added in the "Additional Notes" section below.

Onsite Point of Contact Name and Email or Phone NumberRequired *

Will activity be recorded?Required *

Will activity be recorded? Yes Will activity be recorded? No

Will this activity be livestreamed?Required *

Will this activity be livestreamed? Yes Will this activity be livestreamed? No

Prep Material

Please provide any available prep material for the provider to use to prepare for the activity. This includes but is not limited to an agenda, run of show, speaker and/or participant names, prepared remarks, fliers, websites, PowerPoints, videos, notes, etc. Websites and short notes can be provided below. Files can be sent to smoutinho@ccc.edu

Website or links to prep material

Additional Notes

Please include any further information for us about this request. Preferred provider? Unique parking instructions?

Additional Notes

CCC Use Only

CCC Staff

CCC Staff Yes CCC Staff No

Type of Service - Accommodate