Tinicum Facility Use Application
Application for use of the Tinicum Elementary School by an outside organization Classifications C,D,E & F. Application must be submitted three (3) weeks prior to event.
Email address *
Name of Organization *
Your answer
Organization's Address *
Your answer
Phone Number *
Your answer
Date of Application *
MM
/
DD
/
YYYY
List day(s), date(s), and time(s) requested to use the facility (include and specify set up and clean up times required): *
Your answer
List area(s) of the facility requested to be used *
Required
State purpose of use (be specific): *
Your answer
Will an admission fee be charged? *
Equipment Request: Please detail below the type, quantity and location of all equipment requested for your event. (i.e. 2 tables, 6 chairs set up in lobby) If no equipment is requested, type "none". *
Your answer
List name, address, phone number and email address of two responsible officials, one of whom will be present at the time the facilities requested are being used and who will accept full responsibility for adherence to School District regulations.*
Name (1st person making request) *
Your answer
Address (Street/City/State) *
Your answer
Phone *
Your answer
Email Address *
Your answer
Name (2nd person making request) *
Your answer
Address (Street/City/State) *
Your answer
Phone *
Your answer
Email Address *
Your answer
I(we) certify the I(we) have read and understand the rules and regulations of the Palisades School District concerning the use of School Buildings and turf field and further that I(we) forever release the Palisades School District, its directors, agents and employees from all claims, actions and charges whatsoever arising out of the event(s) conducted on the above-mentioned date(s) for which this application is submitted. That upon prompt notice it will defend all actions, suits, complaints or legal proceedings of any kind brought against the Board of Education and any of its agents or employees and further it would hold harmless and indemnify the said School Directors and School District, from any expenses and judgments or decrees recovered against them as a result of the said use of these facilities.* *
Certificate of Insurance
The organization must submit a certificate of insurance with the following information entered as additionally insured:

Palisades School District
39 Thomas Free Drive
Kintnersville, PA 18930

The certificate of insurance must be emailed to: aschlosser@palisadessd.org

Ignoring rules or abusing the facility could result in fines and/or loss of access to all of the Palisades School District facilities.

I hereby acknowledge that all the information listed above is true and that I have read and understand the rules and regulations regarding the use of the Palisades School District facilities. By typing your name in the box you are submitting your electronic signature to the Palisades School District: *
Your answer
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