Appendix D 
UVI Student Activities: Revised Summer 2013 
 
 
Student Activities Office 
On/Off Campus Activities Approval Form 
 
Name of Organization: ___________________________________________________________ 
Activity: _____________________________________     Date: _______  Time: ______-______ 
Purpose of Activity: 
______________________________________________________________________________
______________________________________________________________________________ 
Location: ____________________ Admission/Cost to Participate_________________________ 
 
Is this event open to the University public?  
 
 
 Yes  
 No 
 
Will this event be published in the local oral/print media?              Yes              No 
 
Special Arrangement/Request: (List all items that you would need from Student Activities.) 
______________________________________________________________________________ 
 
______________________________________________________________________________ 
 
______________________________________________________________________________ 
 
______________________________ 
______________ 
________ 
____________ 
Person in Charge of Activity     
 
E-mail Address 
Mailbox# 
Telephone No. 
UNIVERSITY OFFICIAL TO SUPERVISE THE EVENT ____________________________ 
 
________________________ 
________ 
_______________________        ________ 
    President’s Signature 
 
    Date                 Advisor’s Signature 
            Date 
 
CHECKLIST: (please make sure that these things are in place) 
 Cleaning/Security Deposit 
 
  Check Requisition(s) to cover expenses 
 Alcohol Permission request                List of students participating for Walk-A-Tons 
 
 Name of Police Officers:  ____________________________    _______________________________ 
 
 
 
       Name                      Phone #                Name                            Phone # 
 
DO NOT WRITE BELOW THIS LINE___________________________________________ 
 
 UVI Security Officer       cooler___     cash pan____   table____ 
 Other items__________________________________________________________________ 
 
Approved: 
 Yes  No  
Comments: ______________________________________ 
       ______________________________________ 
       ______________________________________ 
_______________________      ________        ______________________________________ 
Student Activities Supervisor         Date               
*Please walk with this form and contact security at 693-1530 before to open and after the event to secure the site* 
 
        
cc: Security, Physical Plant, Custodial, ITS, Cafeteria 
 
 
 
 
 
 
 
 
 
 
                           
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