DIG LA Interest Form

Name *

Email *

Office Phone *

Cell Phone

Department *

Class ID/Class

If your proposal is not based in an academic course, but departmental or organizational in nature, please identify the department and/or organization instead.

Event Location

Name of Event

Date(s) of Event

Separate multiple dates with commas

Location

Description of Event

Academic and/or Cultural Purpose *

Event must have an academic/cultural purpose that furthers/reinforces the courses curriculum. Please explain how the event will directly correlate with your coursework. (Examples: If there is an assignment, explain what that will look like. If there is a discussion which will lead to a reflection, then explain how that might occur).

Product that will be produced from trip/event? *

The IRA Advisory Board must determine that the program involves enrolled students in significant out of class activity which results in a planned product; such products include, but are not limited to, competition or performance before an audience, a display of equipment or material of instructional value to the University community, or a written or electronic publication or other media available to students of the University.

Approximate Cost of Event (not including transportation) $

Number of students impacted/anticipated

Will you require a bus?

Yes

Other Information

Leave this field blank

California State University, Northridge

Division of Student Affairs

Office of Student Involvement and Development

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DIG LA Interest Form