Public Forum Request Form
Before completing this form, read the Freedom of Expression Policy 6.4 located at https://policies.mga.edu/policy-manual/section-6-campus-affairs/6-4-freedom-of-expression-policy.php

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Name of person requesting activity *
Name of organization (if applicable)
Email address (insure this to be a valid email address as this will be the primary method of correspondence) *
Approximate number of people participating as part of your organization, activity, or event *
Address *
Telephone *
Specific activity/event description (i.e. speech or rally, march. picketing, distribution of literature, etc) *
Specific purpose of the activity
If this event is being co-sponsored, list other group(s) and describe their involvement
Other information pertinent to the event
Name of primary speaker *
If there will be other speakers, list the name(s) of the additional speakers
Requested Date 1 (Month/Day/Year) *
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Requested Date 2 (Month/Day/Year) *
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Time *
Middle Georgia State has five campuses. Which campus location are you requesting? See Public Forum map. *
Backup Dates (Optional) - If the requested dates are not available, do you have another possible date? (Month/Day/Year)
Any use of amplified sound, other than amplified sound used in connection with University-sponsored events, must only be intended to be heard in the immediate area of expression in order to minimize any disruption of the central academic mission of the University.  Please indicate if you will use any equipment during the event. List type.
Statement of Compliance - I have read the Freedom of Expression Policy 6.4 and will comply with that policy *
The authorized representative of the speaker or group acknowledges compliance with the Freedom of Expression Policy 6.4 and acknowledges that the University will not be held responsible for the actions of participants in the expression *
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