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St. Luke's Simulation Center Skills Session / Equipment Request Form
Please complete this form at least one week prior to your event.
Requester Information
First & Last Name:
Phone:
Email:
Today's Date
Event Information
Type (mark all that apply):
Course
Simulation
Skills / Workshop
Demo
Tour
Other
If other, please decribe:
Course / Program Title:
Goals & Objectives:
Lead Contact for Session Planning and Development:
Type of Learners:
Number of Learners:
Location:
Anderson Exam Suites
Anderson Sim Lab
Anderson Skills Lab
Bethlehem Estes Exam Suites
Bethlehem Estes Sim Lab
Bethlehem Ed Center Sim Lab
Bethlehem Ed Center Skills Lab
SH Sim Lab
SH Skills Lab A
SH Skills Lab B
Sim Truck
Other: Request in the Description/Comments field
Date:
Start Time:
End Time:
Description / Comments (if needing multiple date, please add them here):
Equipment Information
List:
Requested Date/Time of Pickup:
Requested Date/Time of Return: