Building & Facilities Use Request Form
Please fill out the following form as thoroughly as possible. If you have any questions or changes to make to your original submission, please contact Vicki Fleury at vfleury@wrsdsau59.org or by calling 603-286-4116 ext 8111. Thank you!
Email address *
Applicant Name: *
First & Last Name please
Your answer
Mailing Address: *
Your answer
City/Town: *
Your answer
State: *
(i.e. please enter "NH" not New Hampshire)
Your answer
Zip Code: *
Your answer
Primary Phone#: *
ex: (000)000-0000
Your answer
Secondary Phone#: *
ex: (000)000-0000
Your answer
Email address: *
Your answer
Name of Organization: *
Your answer
Title of Event: *
Your answer
Type of Organization: *
Please select one option that best describes your organization
Date(s) of Use: *
Either enter single date as mm/dd/yyyy or range of dates as mm/dd/yyyy to mm/dd/yyyy (if odd schedule please enter detailed schedule information here as best as possible. If you need more room, add details in "special requests" section of this form.)
Your answer
Event Description: *
What will be happening at this event?
Your answer
School or Building Requested: *
Please select building you plan to be using for this event
Required
Location within the building:
Check all that apply - if selecting "Classroom" please specify # of rooms needed & room #'s on "other tab" if possible.
Do you have access to the building? *
Event Start Time: *
Time
:
Event End Time: *
Time
:
Setup Begin Time:
Time
:
Breakdown End Time:
Time
:
Will general public be admitted? *
Number Attending?
Approximate guesstimate is fine, just to give us an idea for planning purposes.
Your answer
Who will attend?
Your answer
Will admission be charged? *
If yes, how much?
Your answer
For what purposes will the profits be used?
Your answer
Add to the schedule of public events? *
Name of On-Site Contact: *
First & Last name of the person who will actually be on-site the day of the event
Your answer
Cell Phone#: *
ex: (000)000-0000
Your answer
Billing Address (if different than mailing)
Your answer
FEIN:
Your answer
Liability Insurance Company Name:
Your answer
Policy Number:
Your answer
Coverage Dates:
mm/yyyy to mm/yyyy
Your answer
What do you need from us? *
Please select any areas that you need support from us for your event. Please specify those needs in the "description of setup" section of this form. Fees may be associated with some requests.
Required
How many chairs? *
(if you do not need chairs, simply enter 0 or N/A)
Your answer
How many tables? *
(if you do not need tables, simply enter 0 or N/A)
Your answer
How many extension cords? *
(if you do not need extension cords, simply enter 0 or N/A)
Your answer
Description of setup and other needs/special requests: *
(i.e. tables and chairs setup facing what direction? Setup dining room style, auditorium style, bleachers pulled out, floor tarps put down, basketball hoops up...be as specific as possible. If you just need the requested materials but want to set it up yourself, simply say "leave materials, will setup myself." REMINDER: If you do not enter it here, please do not expect it to be done for you when you arrive. If you do not need any special accommodations, please enter NONE)
Your answer
Please read attached release of liability agreement and select appropriate response: *
Captionless Image
Applicant's Signature: *
First & Last name
Your answer
Applicant's Title: *
Title within organization that is requesting use of the building
Your answer
Date: *
MM
/
DD
/
YYYY
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