EmailMe Form - Instagram Takeover Request

Name *
First Last
Class *
Group Name
Email *
Instagram handle *
Twitter handle *
Requested Date *
MM / DD / YYYY
Note: Must be at least 7 days from today's date
Today's Date
MM / DD / YYYY
Start Time
HH : MM AM/PM
End Time
HH : MM AM/PM
Why should you do a takeover? *
Submitter's Information
Name *
First Last
Email *
Phone
### - ### - ####
Signature
Clear
Checkbox *
I agree
By checking this box, you have reviewed and agree to adhere to the rule as outlined above.