Non-UTHSC Students on Campus

Information Required for UTHSC and Non-UTHSC Groups

Applications cannot be submitted and will not be reviewed unless all information is complete. All applications for Summer Programs must be submitted by May 1st of the current year. The application period is February 1st through May 1st. All programs will incur some administrative costs.

NOTE: The approval process can take up to 2 to 3 weeks before you receive a response. Incomplete documentation will result in termination of application for use of UTHSC facilities.

For questions concerning the approval process contact Sade Baker at (901) 448-2627.

Program Details

Start Date:

End Date:

Total Number of Students in the Program:

Age range:

Did you select the students to participate in your program? Yes No

Did the students apply to participate? Yes No

What were some of the criteria for selection?

Briefly explain your criteria for selecting students to participate in the program:

(100 word maximum)

Program Description:

(100 word maximum)

Contact Information

Please provide contact information for the person that will be on campus throughout the duration of the program:

First Name:

Last Name:

Phone: Example: 555-555-5555

Email: Example: name@example.com

NOTE: A copy of the completed Summer Program Resource Request form will be sent to the email address provided.

Scheduling/Equipment Requests

Itemized Listing of Resource/Service Requests for the TOTAL length of your program:

Row	Date	Time (hours)	Type of room	Number of students per room	Equipment needs
1

Sample Program Schedule

Please provide a 5 day sample schedule for your program following the examples given below.
(None of the fields can be left empty, if your program will be on campus for less than 5 days please write "None" or "Not-Applicable" in the corresponding field.)

Monday:

example

Tuesday:

example

Wednesday:

example

Thursday:

example

Friday:

example

Campus Services and Liability Agreement

Liability Agreement

UTHSC Liability Disclaimer

All students must complete liability forms, read rules and regulations, and agree to guidelines for use of UTHSC spaces.

Do you agree to these terms? Yes No

Food Services Agreement

Food Services Disclaimer

Chartwells is the Campus Catering Service and has the right of first refusal for all food served on campus unless Chartwells gives you a waiver.
You are responsible for making arrangements for food with Chartwells.
Please review the Chartwell Catering policies.

Do you understand the terms/conditions of the Food Services Disclaimer? Yes No

Will the program require food? Yes No

Parking Services:

Will staff and/or students participating need parking? Yes No

Parking Fees

Are funds available to pay for UTHSC parking for all participants? Yes No

Accident Insurance:

Does the program provide accident insurance for participants? Yes No