Student Use of Audio-visual Equipment on Campus

Dunn Library Media Services Department
Statement of Responsibility
For Student Use of Media Equipment on Campus

PLEASE NOTE THE FOLLOWING: --I understand that in using equipment owned by Simpson College, I become responsible for the care and security of the equipment. --If the equipment is damaged or lost, I agree to be responsible for paying all necessary costs of repairing or replacing the equipment.

Equipment Needed:
Name of Group / Organization:
Location of Use:
Storage Location:
Date of Use:
Date of Request:

REQUESTER INFORMATION:

Faculty / Adviser Name:
Faculty / Adviser Department:
Faculty / Adviser Email:
Faculty / Adviser Phone:
Student Name(s):
Other Information: