UW OMAD Recruitment & Outreach
Visitation Request Form
 
* PLEASE FILL IN THESE REQUIRED FIELDS
Visitation Contact Information:
* Name of Organization or Program:
* First Name:
* Last Name:
* Phone Number:     Ext:
Fax Number:     Ext:
Cell Phone Number:
* Email:
(Your confirmation email will be sent here)
  If you have more than one email, separate them by a comma.
How did you hear about the Student Outreach Ambassador Program?
Logistical Details: (fill in the required fields and any others that apply)
* Location: On Campus Off Campus
* Arrival:  
Date:
  Please use this format for Date: M/D/YYYY
(3/5/2009 not 03/05/09)
Time:
  Please use this format for Time: H:MM
(9:00 not 9)
* Departure:  
Date: M/D/YYYY
Time: H:MM
  If you have more than one preferred time range, please indicate in comment area below.
Number of Vehicles:
* Number of students:
Number of Underrepresented Students:
* Grade Level:
 

Hold control key to select multiple items.
Please note that the admissions presentation is not available for grades 8-10. If you will be bringing students in lower grades than the listed, please indicate in the comment box below.
* Preferred Activities: (Checks all that apply)
Please describe your organization and any background information on your group (of students) that may assist us in planning an itinerary for your visit
Comments and other requests: (information that does not fit the above fields)