Facility Usage Request Form
Name of Organization
Your answer
Contact Person
Your answer
Email Address
Your answer
Address
Your answer
Phone Number
Your answer
Date of Activity
MM
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DD
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YYYY
Start Time
Time
:
End Time
Time
:
Specific Description of Activity
Your answer
Areas of the Facility to be used (Please check all that apply)
Required
If Other, please explain
Your answer
Please describe any special needs in any selected area of the Facility
Your answer
Estimated Attendance
Your answer
Admission Charge
If YES, please list amount of Admission Charge for the event
Your answer
Special Equipment Needed (Please check all that apply)
Required
Custodial Services Needed (Please Describe Specific Needs)
Your answer
Safety and Security Guidelines: All parking of vehicles for events must be in the student parking lot to the southwest of building and access made through student (west) entrance of the facility unless otherwise directed by school personnel. The organization may be asked by the administration to provide a list of potential attendees and workers for the event at least twenty-four hours in advance. Once at the school, access to all other areas of the facility is strictly prohibited without approval by school personnel. All areas of the facility should be closed, locked, and returned to previous condition when activity is concluded. If members of the organization view any activity or situation of a suspicious or dangerous nature, a representative must contact law enforcement and/or school personnel immediately.
I have read and agree to the Safety and Security Guidelines
Fees and Expenses: It is to be understood and agreed that additional personnel required for the event (i.e. custodians, etc.) and other costs incurred by the school district will be paid for by the organization as a fee charge. In addition, the organization agrees to be fully responsible for the building and equipment during the duration of usage. Any damages incurred during the usage of the facilities will be the responsibility of the organization. Adult supervision must be provided by the organization and the organization must enforce all policies and regulations as set forth by the Board of Education and Administration.
I have read and agree to pay any Fees and Expenses
Waiver of Liability: Central Community High School shall be indemnified and saved harmless by the organization using the facilities listed above from any and all claims of every character or nature arising out of or resulting from the use of said facilities. (The organization may be asked to provide the district with a certificate of insurance.)
I have read and agree to the Waiver of Liability for Central Community High School
Signature of Individual Representing the Organization (*A copy of this form will be returned to organization with approval or denial of usage as designated.)
Your answer
Date of Request
MM
/
DD
/
YYYY
Submit
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