Herman Ostrow School of Dentistry of USC

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Student Club Activity Request Form

Register your student activity club by filling out the form below.

Student Club Activity Request Form

Club Name*
Contact Person Name*

First

Last
Contact Person Position
Contact Person Email*

Enter Email

Confirm Email
Contact Person Phone Number
Activity Name*
Activity Type*
Activity Date*

Date Format: MM slash DD slash YYYY
Activity Start Time

:
HH

MM
Location*
Number of Participants*
Activity Purpose*
Will There Be a Guest Speaker?*
Guest Speaker Name
Guest Speaker Affiliation
Is Guest Speaker Full-Time Faculty?
Is the Event a Fundraiser?*
What will be sold?*
Where Will Funds Be Deposited?*
Would You Like Your Event Publicized on East Lobby Monitor?
Please Upload Your Event Flyer or We Can Create a Slide for You
Faculty Adviser Name*

First

Last
Faculty Adviser Email*

Enter Email

Confirm Email