Single Event / Lecture Capture Request

Event capture is limited to HSLC Lecture Halls (1306,1309,1325,1335 & 1345) between 7am - 5pm, Monday - Friday. Please verify you have a confirmed room reservation that meets the above requirements before completing this form.

To guarantee capture, request should be made no later than 7 days in advance of the event.

Pricing

(Your event may be exempt from charge. See possible exemptions below)

Setup	$150/event
Recording - single source - presenter only (example)	$75/hour
Recording - dual source - presenter and PowerPoint (example)	$150/hour
Live broadcast - single source only	$75/hour
Video Library Site Hosting	NO CHARGE
Annual Series (contact us)	$8000/year

Exemptions SMPH Dean's Office Sponsored
SoN Dean's Office Sponsored
Medical Student curriculum-related or Student Organization Sponsored
Nursing Student curriculum-related or Student Organization Sponsored
PA Student curriculum-related or Student Organization Sponsored
Ebling Library class / event
Public Symposium / Target Audience is the Public
Wisconsin Partnership funded or sponsored event

Verification of exemption may be requested.

Requester information First Name of requester

Last Name of requester

Email address of requester

Phone number of requester

Address of requester

Event Details Title

Capture cannot occur without documented consent of the presenter.
It is the responsibility of the requester to obtain permission from the presenter and copyright clearance for any materials captured.

I have received permission from the presenter to capture this event.

An email notification will be sent to the presenter upon submission of this request form.

Presenter First Name

Presenter Last Name

Presenter E-Mail Address

Room

Date

Start Time

End Time

Burn to CD (available in Room 1240 HSLC, 1 day after event) (Quicktime format)
Post to IME Video Library (What is the Video Library?)

Event Billing Same as Requester
Billing Contact First Name

Billing Contact Last Name

Billing Email Address

Billing Phone Number

Billing Address

Order Form (Estimated Charges)

Setup	$ 150
Number of Sources
Number of Hours ($75/hour per source)		(1 hour minimum)
Number of Live Broadcast hours ($75/hour)		(1 hour increments)
Number of CDs ($25/ea)		(1st CD Free)
Number of DVDs ($50/ea)
ESTIMATED TOTAL	$ 300	recalculate

I agree to these estimated charges

Special Instructions Special Instructions

Please work with Classroom and AV Services prior to event for setup and orientation.
261-1934 or classroom@hslc.wisc.edu