Non-Jefferson Participant / Non-Jefferson Hosted Event

Request for Approval

The following information is being submitted to you for your approval as the related event will host non-Jefferson participants and/or has been submitted by a non-Jefferson party via Jefferson Faculty, staff and/or student.

Please review the details to determine if a Jefferson space should be assigned for this event.

All events must be in support of the One Jefferson Mission.

DEPARTMENT / ORGANIZATION
CONTACT NAME
JEFFERSON CONTACT E-MAIL
JEFFERSON CONTACT PHONE NUMBER
NON-JEFFERSON ORGANIZATION SUBMITTING REQUEST
EVENT TITLE
EVENT DATE(S)
SETUP TIME
EVENT START TIME
EVENT END TIME
DESIRED SPACE (provide 2 alternate spaces in another building)
EXPECTED # OF ATTENDEES
ATTENDEE AFFILIATIONS (i.e.: Penn, Temple, Alzheimer’s Association, etc.)
WILL FOOD BE SERVED?
WILL ALCOHOL BE SERVED?
IS A FEE BEING CHARGED FOR PARTICIPATION?
WILL MONEY BE COLLECTED / HELD ON PREMISES?
HOW WILL THIS EVENT BE PUBLICIZED?
WILL THE MEDIA BE PRESENT?
TIER LEVEL (if your event is to be held beyond the current academic semester please see the Space Management and Room Reservation Protocol: http://www.jefferson.edu/academic-affairs/tju/academic-services/registrar/room_rsvp/protocol.html and provide the appropriate Tier details)


Non-Jefferson Participant / Non-Jefferson Hosted Event

Request for Approval

SUMMARY OF EVENT (please include: target audience, educational, student organization, purpose of event, reception, lecture, ceremony, etc.):

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THIS SECTION IS TO BE COMPLETED BY AUTHORIZING DEAN/DEPARTMENT HEAD

Charge code: / _ _ _ _ / _ _ _ _ _ / _ _ _ _
Is Event Approved: / Yes / No
If event is not approved: / If event is approved
Should requesting department contact your office? If not, please provide contact information. / Yes / No / Should core-educational classes and/or other events be relocated to accommodate this event? Indicating ‘Yes’ will require further approval from TJU Dean. / Yes / No
Please provide reason for declining approval to be submitted to requesting department. / If relocation is not possible, should core-educational classes and/or other events be cancelled to accommodate this event? / Yes / No
Additional Comments:

Please return this form via email to and forward a copy to Security: Katherine Terzis .

Your signature indicates that your department will be responsible for this event and any related charges, cleaning, service support and/or incidents.
Signature / Date
Please Print Name, Title, Department

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C:\Users\lam002\Documents\Documents\Templates\Non-Jefferson Event Approval Form Jan 2016.doc