Request a School Visit | H. Fred Simons African American Cultural Center

**** PLEASE NOTE THAT DUE TO COVID-19 THIS SUBMISSION IS SUBJECT TO CHANGE AS PER UNIVERSITY OF CONNECTICUT'S STUDENT UNION PROTOCOL****

Today's date:*
MM slash DD slash YYYY

This form must be filled out at least ten days prior to the event.
School or organization:*
Name of individual making request:*
First Last
Affiliation with school or organization:*
Email:*
Phone:*
Will you be the contact person on-site during the visit?*
On-site contact:*
First Last
Affiliation with school or organization:*
Email*
Phone:*
Date of visit:*
MM slash DD slash YYYY
Time:

: Hours

Minutes

AM/PM
Alternative date
MM slash DD slash YYYY
Time:

: Hours

Minutes

AM/PM
Attendee Information*
Please give a brief description of the attendees, such as but not limited to: how many students and chaperones will be attending, what grade(s) are represented, etc.
Visit Description*
Please describe what you envision for your visit. For example, a student panel, admissions information, a campus tour, etc. Outline a sample itinerary for when you want your group to arrive on campus, the activities you have planned for the day, and your departure time.
Director Approval*

Type X above. This space is for the Director's signature.
Name
This field is for validation purposes and should be left unchanged.