Form Bo-1 - Application For Use Of Dchool Buildings, Facilities Or Grounds (Hawaii) Page 2
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1
2FORM BO-2, Rev. 5/09
Application No.
Application No.
DEPARTMENT OF EDUCATION—STATE OF HAWAI’I
STATEMENT INDEMNIFYING STATE AGAINST LIABILITY CLAIM; CIVIL DEFENSE EMERGENCY
NOTICE; SPECIAL PROVISIONS; AND NATIONAL POLLUTANT DISCHARGE ELIMINATION
SYSTEM (NPDES) NOTICE
(Application for Use of School Buildings, Facilities or Grounds)
School:
INDEMNIFICATION STATEMENT
The undersigned individual(s), group and/or organization, his or
their heirs, personal representative and assigns, or its officers,
directors, members, agents, employees, successors and assigns,
for and
in
consideration of the State of Hawaii Department of
Education permitting and allowing the use of the designated
school rooms, buildings, and/or facilities jointly and severally
agree(s) to indemnify and save harmless the State of Hawai’i
Department of Education against any and all loss, liability,
demands, claims, suits, action or proceedings of every name,
character and description which may be suffered or incurred by or
brought against the State of Hawaii Department of Education for
or an account of any inquires or damages to any person or prop
erty received or sustained by any person, directly or indirectly, by
or in consequence of the use of the facilities by the undersigned
individual(s), groups and/or organization.
CIVIL DEFENSE NOTICE
In the event of a Civil Defense declared emergency during non-
school hours, the undersigned is responsible for the safety of
their program participants. The Department of Education is not
obligated to provide for Civil Defense emergencies during non-
school hours except when the applicable school is designated for
use as a shelter by the American Red Cross.
NATIONAL POLLUTANT DISCHARGE
ELIMINATION SYSTEM (NPDES) NOTICE
The National Pollutant Discharge Elimination System (NPDES) is
a regulatory program administered by the United States
Environmental Protection Agency that calls for the control and
management of storm water pollution. In Hawaii, our storm water
drainage systems were designed to prevent flooding by channel
ing storm water into drains that discharge through outlets along
the coastline.
However, the storm water drainage systems were not designed
for the disposal of waste or pollutants. In order to protect the
environment and fulfill our pollution prevention (P2)
responsibilities, the Department of Education must implement
best management practices (BMP5) as part of a storm water
management plan (SWMP).
The undersigned understands that every effort should be made to
prevent pollution as a consequence of using school facilities.
Waste and pollution if not curtailed will enter storm drains and
eventually make its way to the ocean. Organizers and partici
pants can help by preventing litter and minimizing the use of
autos on campus by carpooling, riding bikes, and using public
transportation. Report any illegal dumping and observed viola
tions by calling the City Illegal Dumping Hotline at 296-5656
(Honolulu) or the respective county offices (neighbor islands).
SPECIAL CONDITIONS
(to be completed by school administrator as needed)
ACCEPTANCE AND ACKNOWLEDGEMENT BY USER
The undersigned hereby accepts and acknowledges the above (statement, notices, and special conditions).
Signature
Date
Name of Organization
NOTARIZATION (OR) SCHOOL ADMINISTRATOR SIGNATURE
Subscribed and swom to before me this
of
Judicial Court.
Notary Name:
Notary License No.:
Notary Signature:
Commission Expiration Date:
-OR
School Principal or Vice-Principal
Date
DISTRIBUTION: ORIGINAL-School, COPY-Requestor
(9/2015)
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