FORM BO-1, Rev. 7/09
Application No.
(School)
DEPARTMENT OF EDUCATION
-
STATE OF HAWAII
APPLICATION FOR USE OF SCHOOL BUILDINGS, FACILITIES, OR GROUNDS
(Application must be received by the School at least 10 working days prior to requested date of use.)
WE RESPECTFULLY REQUEST THE USE OF:
D CLASSROOM
0
AUDITORIUM
0
LIBRARY
0
DINING ROOM
0
GYMNASIUM
0
OTHER__________________
AT
ON THE FOLLOWING DATE(S):
(monthldaylyear)
FROM
a.mip.m. TO
FOR THE PURPOSE OF (GIVE INFORMATION ON USE):
APPLICANT’S
NAME
AND
ORGANIZATION:
ADDRESS:
PHONE:
Home:
Bus.:
PLEASE ANSWER THE FOLLOWING QUESTIONS
AND
AFFIX YOUR SIGNATURE:
1.
IS YOUR ORGANIZATION TAX-EXEMPT NON-PROFIT? (TAX I.D. NUMBER:__________________________________
0
YES
0
NO
2
IS THIS A GOVERNMENT SPONSORED ACTIVITY? (SPONSORING AGENCY:
D
YES
Q
NO
3.
IS THIS A SCHOOLIDOE SPONSORED ACTIVITY? (SCHOOL ADMINISTRATION:
)
0
YES
0
NO
4.
HAS YOUR ORGANIZATION LEASED THIS SITE REGULARLY IN THE PAST?
0
YES
0
NO
If yes’, you are hereby notified that leases may be renewed annually but not exceeding five (5) years. You are expected to make a good faith
effort to retain a more permanent or alternative location for your activities
during
the period of the lease. If such a good faith
effort
is lacking,
your lease may not be renewed.
Total number of years your organization has been using the school’s facilities:
5.
iS THIS A PERSONAL OR PRIVATE BUSINESS ACTIVITY?
0
YES
0
NO
6.
IS THERE A FEE, TUITION, OR DONATION COLLECTED?
(AMOUNT:
$__________
PER DAY/PER HOUR)
0
YES
0
NO
7.
DO YOU PLAN TO SUBLEASE THE FACILITY? (Craft Fairs and Carnivals)
0
YES
0
NO
IF SUBLEASING, ARE ALL SUBLESSEES TO BE COVERED BY APPLICANT’S LIABILITY INSURANCE?
0
YES
D
NO
I, the undersigned, on behalf of the organization I represent, have answered
the
above questions truthfully and accurately. If the school facilIties,
equipment or grounds are not properly maintained by the applicant, the State of Hawaii Department of Education will deny further use of school facilities,
equipment or grounds to the individual or organization and seek appropriate restitution for damages incurred. The applicant further understands that the
school facilities and grounds are to be alcohol and tobacco free, meaning that the use of any alcohol or tobacco substances are prohibited at all times on
school grounds or at any school activities. Furthermore, I understand that as a user of school facilities the activIty being conducted shall be lawful. Should
disabled persons wish to participate in the requested use, applicants must make reasonable modifications andlor programmatic accommodations to permit
such participation.
Signature
Date
(To be filled In by the school
ACTUAL FEES
AND
CHARGES:
CODES FOR CASH RECEIPTS:
TYPE
OF REQUEST:
TYPE
I
TYPE II
TYPE Ill
Org. I.D.
SourcelObject
Program I.D.
RENTAL:
$
N/A
$
N/A
$
000
124Q
CUSTODIAL*:
$
$
$
468
42ii.
UTILITIES:
$
N/A
$
$
000
j.
TOTALS:
$
$
$
(Checks payable to: DEPARTMENT OF EDUCATION)
POLICE ANDIOR LIFEGUARD REQUIRED: (NUMBER OF POLICE AND/OR LIFEGUARDS REQUIRED:
0
YES
0
NO
LIABILITY INSURANCE REQUIRED: ($1,000,000 liability insurance for craft fairs, carnivals, and
certain
athletic events)
Policy No.
0
YES
0
NO
YOUR REQUEST FOR USE OF SCHOOL FACILITIES OR GROUNDS IS HEREBY:
0
APPROVED
0
DISAPPROVED
Signature:
Date:
(Principal IDesignee)
REASON FOR DISAPPROVAL:
0
FACILITY REQUESTED NOT AVAILABLE
0
OTHER_____________________________
0
CUSTODIAN1STAFF NOT AVAILABLE
DISTRIBUTION: ORIGINAL-School, COPY-Requestor
(9/2015)
)
Company_____________________________