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Facility Use Request
Required form for consideration of Knoxville Community School District facility use. PLEASE NOTE: Liability insurance is required to rent school facility. Minimum liability requirements: $1 million and Knoxville Community School District listed as an additional insured. Please be sure to read the board policy noted in the form below.
Checklist prior to completing this form
1. Read Board Policy 1004.1 (linked below) prior to submitting this form. *Liability Insurance is required to use KCSD facility (specific policy needs: minimum liability limit of $1 million and Knoxville Community School District as additional insured.)
2. Read all questions of this request form before entering your answers.
3. If for a youth sports team, please gather your team roster (including adults and kids) before beginning as it is necessary to submit this form.
QUESTIONS about facility availability or other? Email: Lisa.Willis@kcsd.k12.ia.us
Organization or Group Name *
Your answer
Is your organization affiliated with Knoxville Schools? *
(Note: Knoxville School activities and events take priority.)
Required
If non-school organization, PLEASE READ Board Policy 1004.1* (Community Use of & Regulations of School Facilities) and CHECK AGREE. *Rental fees are listed in this policy for your convenience
Place of Meeting/Event *
Required
Purpose of Meeting/Event *
(Type of Activity, Event or Sport)
Your answer
Roster & Expectations *
Please add your roster (ADULTS & children involved), expectations of the team / group and/or any other information that be helpful in scheduling your team.
Your answer
Date(s) Needed *
Please note: The form allows for multiple dates with the SAME start and end TIMES. If you have varying start times, use separate (additional) forms. Examples: Practice 7:00 pm on 5 consecutive Mondays --- One Form. Practice 5:00 pm on 2 Mondays and 3:00 on Tuesdays --- Two Forms
MM
/
DD
/
YYYY
Additional Date (2)
MM
/
DD
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YYYY
Additional Date (3)
MM
/
DD
/
YYYY
Additional Date (4)
MM
/
DD
/
YYYY
Additional Date (5)
MM
/
DD
/
YYYY
If more than five dates are needed please list here. (mm/dd/yy format)
Your answer
Start Time (When the building needs to be ready including prep time) *
Time
:
End Time *
Time
:
Will you be serving food? *
Required
If you are serving food, please describe.
Your answer
Will you require any special equipment? *
Required
If you are requiring any special equipment, please describe.
Chairs (#), Tables (#), Sound system, Projection system, Specify stage equipment, Podium, Food Service Equipment
Your answer
Is there anything else we should know?
(additional event details)
Your answer
Contact Name *
Your answer
Contact Email Address *
Your answer
Contact Phone Number *
Your answer
Alternate Phone Number
Your answer
Please email your certificate of insurance to Lisa.Willis@kcsd.k12.ia.us for Ryan Rump, AD. (Specific policy needs: minimum liability limit of $1 million and Knoxville Community School District listed as an additional insured.) Additional space below is provided for additional information you wish to provide.
Your answer
For Office Use Only
Rental Charge:

Other Charges:

Reasons for Other Charges:

Custodians Assigned:

Cooks Assigned:

Complaints, Damages, Problems Reported:

Date Fees Paid:

For Custodian Use Only
Actual time the building was used by the Groups or Individual ________ to ________ Total Time ________

Total Time Worked at the Event ________ including preparation and cleanup.
https://docs.google.com/document/d/1kFT9kSonl66ICkCybtT0_GutOWgyBEjRimtOiwgO0Iw/edit?usp=sharing

PLEASE NOTE: Liability insurance is required to rent school facility. As noted above, please read and submit all materials noted in board policy (https://docs.google.com/a/kcsd.k12.ia.us/document/d/1D8fGVxoAzoLQwTDT6C7le6u3QiDvc9Gzbp0MfncQoR4/edit). Materials (such as proof of liability insurance) may be submitted to Lisa Willis for Ryan Rump, AD (lisa.willis@kcsd.k12.ia.us).
Your answer
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