Media Services Request

Name

Email*

Summary of Issue or Request*

Please provide a short overview of the issue

Location*

Request Type*

Cell/Phone Number*

Room Number or Location

Detailed Description of the Problem (including any error codes)

Department*

Event Name*

Main Room or Area*

Event Recurrance?

Start Date*

Start Time*

:

End Date*

End Time*

:

Pickup Date*

Pickup Time*

:

Equipment Needs

Electronic Equipment

Laptop (checkout for the semester) Laptop DVD Player Canon Camera Sony Camcorder Sound Cart Large Projector Screen

Electronic Equipment

Laptop DVD Player Portable Sound System (2 speakers, 2 mics, cd player and built-in mic stand)

Handheld Mics

Headset Mics

Laptop Mics

Internet Connection

Yes

Miscellaneous AV Equipment

AV Cart with AC Heavy-duty extension cord

Technical Assistance

Set-up only Entire event

Describe Dress Code

Terms Agreement*

I Agree to Terms Below

I agree to be financially responsible for any loss or damage occurring to the equipment while it is in my care.
I agree to keep said property in good and proper condition as determined by the District.
I agree to be the only person to use the equipment.
I will return it to the WHCL Media Specialist on the date stated below.

Additional Details*

Please provide a detailed description of the request.