Clatskanie School District - Facility Use Request

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Name of Organization (including Tax ID number): *

Description of Event *

Start Date of Activity (Month/Day/Year) *

End Date of Activity (Month/Day/Year) *

Time Enter / Set Up *

Time

Start Time of Activity *

Time

Exit Time of Activity *

Time

Approximate Expected Number in Attendance (Adults / Children) *

Building Requested *

Clatskanie Mid/ High School

Clatskanie Elementary School

Old Middle School Gym (aka....Barn)

Bus Garage

Required

Area To Be Used *

Classroom - Enter Classroom # in Notes Below

Kitchen

Commons

Auditorium

CMHS Upper Gym

CMHS Main Gym

CES Cardiff Gym

CES Old Gym

CMHS Football Field (please answer next question)

CMHS Baseball Field (please answer next question)

CES Lower Field

Bus Garage Conference Room

Other:

Required

Football / Baseball Field : Will you need access to the Snack Shack? If so, a separate form will be sent to you to fill out. *

N/A - not using baseball / football field

YES, I would like access to the snack shack. (A separate set of instructions and expectations for use of snack shack will be sent to you.)

NO, I do NOT need access to the snack shack.

Notes: *

Purpose of Activity *

Fundraiser

Community Non-Profit

Public Services

For Profit

For Whom or What Will Proceeds Be Used? *

List Equipment Needed / Access: (Please be specific) *

The following conditions and/or charges may apply. Please read and check boxes showing that you read and understand. *

A district kitchen employee must be present during use of kitchen facility.

If custodial services exceed normal daily duties for any district facility, a charge may be levied.

Auditorium lights and sound system may only be used by trained personnel, and a charge may be applied.

If using the snack shack, you must supply your own food items. Any food/misc. items used that are not brought in by your organization will be charged to your group. Any appliances used must be cleaned and put back in the same place.

Required

Organization using the requested facility is responsible for clean up and any damage. Please read and check each box showing that you read and understand. *

Final approval will be given by the district administration.

The individual submitting the request and the organization represented agrees to hold the school district and related personnel harmless from any physical damage or personal injury that may occur due to the use of district property.

Keys may be picked up, following final approval, the last working day before the requested activity. Keys must be promptly returned.

Final approval will be emailed to the person filling out the request. Please make sure all fields below are filled out.

Required

Do you have liability insurance?

YES (attach a certificate with CSD as additional insured)

NAME: *

EMAIL ADDRESS: *

PHONE NUMBER: *

MAILING ADDRESS: *

Please click the link below. Read Part II, print and sign. Email signed document to the email addresses listed on the form.

Facility Use Form - Part II

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