Qualtrics Survey | Qualtrics Experience Management

General Information

Title of Event

Date of Event (MM/DD/YY)

Start Time & End Time of Event (e.g., 10am-5pm)
Please provide the actual start and end times of your event

Recurring Dates
If this is a recurring meeting, please provide additional dates here.

Primary Contact

The primary contact will be responsible for all event and billing details.

First and Last Name

Contact Email

Confirmation for this event will be sent to the email address listed above.

Phone

Department or Group

Billing Information

A valid Weill Cornell Medicine (WCM) fund number, NewYork-Presbyterian (NYP) account number or authorized credit card is required to hold your reservation, even if your event incurs no charges.

How will you be paying for any event charges?

Credit Card (If paying by credit card, a separate authorization form will be sent to you.)
WCMC Fund Number
NYP Account Number

WCM Fund/NYP Account Number
Please enter the 8-digit WCM fund number or 6-digit NYP cost center that can be used for payment.

Room Requirements

Number of Attendees

Preferred Room

While we try to meet all specific room requests, events may be placed in other spaces based on availability and our discretion. Please contact the Griffis Faculty Club directly: griffisservices@med.cornell.edu regarding reservations in their lounge, dining room or Harkness Courtyard.

Desired Room Setup

Please note that not all room configurations are available in all spaces. If you select "Please contact me", a representative will follow up to help you plan your space configuration.

Do you need audiovisual (AV) equipment or technical support?
Please note that equipment built into the room, such as a podium mic, speakers, or projector can only be operated by an ESO Technician.

Yes
No

Do you require Zoom Meeting or Zoom Webinar support?

Yes
No

Do you require a recording of this event?

Yes
No

Will you have a panel discussion?

Yes
No

Catering Requirements

Does your event require food service?

No
Yes, from the Griffis Faculty Club
Yes, from a caterer other than the Griffis Faculty Club

If you select the Griffis Faculty Club for your food service, you will need to send an email to griffisservices@med.cornell.edu. A representative will contact you regarding your catering request to help you plan a menu and times of service.

Other Requests

If you have other requests or things we should know to help book your event, please enter them here.

An ESO team member will respond to your request within 24-48 hours. If you do not receive a response within 48 hours, please email eventservices@med.cornell.edu.

For all same-day or next-day requests for an auditorium or technical support call 646-962-9717. For Conference Room requests call 646-962-6112.

Agreement

By completing the section below, I, on behalf of my department, group or organization, acknowledge that I have fully read and agreed to all applicable Event Services Policies. I recognize that completion of this form does not guarantee me space for my event. I understand that I will have to approve a provided event quote before my event is confirmed. I agree to notify Event Services as soon as possible if my event needs to be rescheduled or canceled.

I Agree