Distance Learning Class Request

*Required Fields

Contact Information    


*Instructor Phone:

*Instructor Email:

Check if Requestor Information is the same as Instructor Information otherwise complete the following:

*Requestor Name:

*Requestor Phone:

*Requestor Email:

Course Information    
*Course Title   Fall Semester
Spring Semester
Summer Session
*Course Number  
Target Audience
(i.e. MD's, RN's, Educators...)
*Start Date Calendar

Days of Week (Check all that apply):

M   Tu   W  Th 

*End Date Calendar
*Start Time AM PM  

If class does NOT run weekly, please indicate all dates needed:

*End Time: AM PM  
Exclude Dates:  
Room Information    
Class Origination Site
1st Room Preference
2nd Room Preference
Distance Video Locations    
Distance Site 1
Distance Site 2 Other Distance Site
Requested Services    
Archive videostream (Provide URL if Archived)
Live videostream    
Phone Bridge Number of audio participants


Please review your information prior to submitting your request. You will not be able to modify this document once submitted.


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Form Updated 9/16/2014