Student Outreach Ambassador Visitation Form


Fields in red are required information
Visitation Contact Information:
Name of Organization or Program:
First Name:    Last Name:
Phone Number: () -     Cell Number: () -
E-Mail:
If you have more than one emails, separate them by a comma.
How did you hear about the Student Outreach Ambassador Program?
Logistical Details: (fills in the red fields and any other that applies)
Location: On Campus Off Campus
Arrival Date:     Departure Date: Format: MM/DD/YYYY
Arrival Time:     Departure Time: Format: HH:MM
If you have more than one time range, please indicate in comment area below
Number of Vehicles:     Number of students:
Number of Underrepresented Students:
Grade Level: Press control key to select multiple items
Preferred Activities:(Checks all that apply)







Other
Please briefly indicate what ethnicity this group will consist of:
Comments and other requests: (information that does not fit the above fields)