Capture and Permission Request Form

Event capture is limited to HSLC rooms - 1244,1248,1306,1309,1325,1335, and 1345 and CSC room G5/119 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

Capture may have been prepaid by your department/division or unit. Please see list below.

Setup	$150/event
Recording - dual source - live streaming available (example)	$150/hour
Live Streaming Only - single source	$75/hour
Prepaid, Annual Series (contact us)	$8,000/year
Prepaid, 10 captures (contact us)	$2,400

Prepaid Partners

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 - This is what will appear in the Video Library so please be specific.

Room

Date MM/DD/YYYY or Aug 12 2009

Start Time

End Time

Burn to CD (available in Room 1240 HSLC, 1 day after event) (Quicktime format)
Post to Video Library (What is the Video Library?)
Post to Restricted Video Library (Restricted to UW Health Sciences students, faculty, or staff to view)

Presenter Information

PERMISSION IS REQUIRED from the presenter(s) before capture can occur. It is important that you list all presenters and their correct email addresses. Presenters will be emailed a link to an online permission form.
Capture will not occur if the online permission form is not completed.

Presenter First Name

Presenter Last Name

Presenter E-Mail Address

Add Another Presenter

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.
classroom@hslc.wisc.edu