Date Received:
________________________
Registration Number:
______________
Student Program Registration and Facility Request Form
To be completed by the sponsoring recognized student organization/student group
Student Organization Name (no abbreviations):
ASA Account:
Primary Contact Name:
Secondary Contact Name:
PSU Email:
Contact Phone:
PSU Email:
Will UPAC (University Park Allocation Committee) funds be requested for this program?
Contact Phone:
YES
NO
IF YES: UPAC deadline to submit requests is 40 academic days prior to program. UPAC Office, room 208 HUB, phone (814) 863-8951, email upac@psu.edu
Event Type:
Event Name:
Anticipated Attendance:
Proposed Location:
Event Date(s):
Day(s) of the Week:
Event Time(s):
Setup Time:
Tear Down:
Description of program (please provide as much detail as possible, include supporting documents if necessary):
If you would like to reserve a HUB Information Table to promote this event, you will need to make a reservation online at www.reservations.psu.edu.
Will there be food and/or beverages at the event?
YES
NO
If the event is in academic or athletic space, no food or drink is permitted, except for bottled water.
Is this program being co-sponsored/planned with another organization, group, or department?
YES
NO
If yes, please list them here:
Is this program a fundraiser?
YES
NO
If yes, and the funds are raised for a philanthropy, please list the non-profit organization:
Please describe the nature of your fundraiser or the product(s) you are selling:
Will you be charging registration and/or admission fees?
Penn State Students:
$
Approximate overall cost of the program:
YES
PSU Faculty / Staff:
NO
$
If yes, please list the prices for the following groups:
General Public:
$
Children / Youth:
$
$
Will an individual(s) or a company be providing a service at your program?
YES
NO
If yes, please explain (i.e. speaker, DJ, instructor, showing a film, performance, etc.):
Will you be paying honoraria or any other expenses for this service (i.e., travel, meals, lodging, stage, lights, sound, etc.)?
Will any payments be made to an individual person?
YES
NO
IF YES, is the individual a United States Citizen?
YES
NO
Will the honoraria cost for any individual speaker/performers be over $10,000?
YES
NO
If checks are made to individuals, a minimum of 15 days will be needed to process payment.
YES
NO
Will this program contain the presentation of material, whether oral, written, or visual, which is sexually explicit or graphically violent?
If yes, explain:
Will community members (non-students, faculty or staff) be participating in this program?
YES
NO
If yes, will anyone under the age of 18 be participating and/or attending?
YES
NO
YES
NO
REQUIREMENTS TO COMPLETE REGISTRATION - FOR OFFICE USE


If requesting UPAC funds, you must go to 208 HUB-Robeson Center to sign out a budget request from UPAC.
Tickets are required since there is admission for your program. All ticketed programs and tickets requiring a small games of chance license, must have tickets printed by
the Union and Student Activities Marketing Office, room 209HUB (usamarketing@psu.edu) and a completed ticket accountability form in the Associated Student Activities
(ASA) Office, room 240 HUB, prior to the selling of tickets. All unused tickets and money collected must be returned to ASA Office at the conclusion of the event. Allow
up to 4 days for ticket requests to be completed.

Since the cost of your admission ticket is $5.00 or more, the impact fee of $.50 per ticket will apply.

Registration fee, raffle, or meal only, no impact fee is required.

Since funds are being collected for this program, all funds must be deposited directly into your ASA account immediately following your program (240 HUB).

A waiver form to serve food will need to be completed with the Events Management Office (125D HUB) no later than 7 academic days prior to your event. All food for
programs that is not provided by Penn State Food Services must be approved and be from a University approved food vendor. A list of approved food vendors can be
found at the following website: www.controller.psu.edu/Divisions/RiskManagement/vendors/caterers. Date received: ________________ Initials: _______________

Contracts are required for this program and must be issued by the University. Contracts will be issued by a Program Registration Advisor once your funding has been
secured or 20 academic days before your program, whichever is first. Submit completed contract: 10 academic days prior to program (209 HUB).

OPP Work order required. Date received: ________________ Initials: _______________

Off Campus Event: Contracts are required. University contracts will not be issued. Please use vendor’s agreement.

Contracts are not required for this program.

Security is required for this program. You must schedule a pre-event meeting 10 business days in advance to coordinate security with Police Services. Please contact
the venue representative to schedule this meeting. Date of meeting: _______________ Initials: _______________

PennDOT permit is required for this program.

Waivers are required for this program. Completed waivers must be returned to 125A HUB.

Room Set-up and Audio/Visual Needs: Must be provided to Events Management (125D HUB) or venue representative 10 days prior to event.
Date received: _______________ Initials: _______________

Date Auction form required. Date received: _______________ Initials: _______________

Copyright permission required: Written proof to show a film must be submitted to Events Management (125D HUB). Date received: ___________ Initials: ___________

Policy AD 39 - Minors involved in University sponsored programs. Policy applies: Date and initial when AD39 form completed: ___________ Policy does NOT apply______

Small Games of Chance License Required. License on file:  Yes

Other:
SIGNATURES
Date received: ________________ Initials: _______________
 No
Date issued: _______________
License Expiration Date:____________________
Date returned: _______________
License Number:____________________
The Program Registration Advisor signature does not indicate approval of a program, only that the program has been registered. This form outlines the offices
that must be worked with in order to conduct your program based on the information provided. The Program Registration Advisor will place an “X” by all
required signatures and N/A for those signatures not required.


Student Organization Representative
Date
Venue Representative - Tentative Hold On Space
Date

Program Registration Advisor
Date


Venue Representative - Space Confirmed
PSU Email
Date

Addendum Form Attached
Date

Contracts Issued
Date
Issued Contracts: Returned to 209 HUB for signatures
Date
Student Activities – 209 HUB for approval of
sexually explicit or graphically violent materials
Date
Other
Date

UPAC - 208 HUB UPAC Request forms
Date


Tickets – 209 HUB Ticket Request form submitted
Date
ASA - 240 HUB Ticket Accountability form submitted
Date


APPOINTMENT INFORMATION
Appointments can be scheduled during regular business hours, Monday - Friday, 8:00 a.m. - 5:00 p.m.
Appointment Required:
Program Advisor:
Appointment Date:
 YES
Office Location:
Appointment Time:
 NO
Revised 8/2015
PLEASE RETURN THIS FORM WITH ALL REQUIRED SIGNATURES TO 125A HUB-Robeson Center
Failure to complete this process with all necessary signatures may have an effect on future programs.