Application For Use Of A School Facility Form
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1
2Independent School District # 709
Application for Use of a School Facility
Submit all copies of application to principal / community education coordinator of
Community Education Office Use Only
requested facility. A copy will be returned to petitioner after processing. Separate
requests must be submitted for each facility. Multiple use of a given facility may be
Code: _______________________________
requested at one time. Applications must be submitted at least two days prior to use
Total Number of Participants: _________
of facility and five days if overtime is required.
Total Participant Contact Hours: _________
Date _________________________
Facility Requested ______________________________________________ Date(s) Requested ______________________________
Activity Supervisor ___________________________ Address _________________________________ Phone _________________
Organization Making Request ____________________________________________________________ Phone _________________
Address of Organization ________________________________________________________________________________________
Purpose of Facility Use __________________________________________________ Hours Facility to be Used ________________
Area to be Used:
Gym
Auditorium
Pool
Cafeteria
Classroom No. ________
Other (please specify) _________________________________________
Equipment Requested:
Tables
Chairs
Microphone
Organ
Auditorium Sound / Light System
Spotlight
Other (please specify) _____________________________________________________
Will admission be charged or a donation requested?
Yes
No
Anticipated Attendance: ________________________
I accept responsibility for building usage fee, supervision, damage and compliance with Title IX requirements.
________________________________________
________________________________________
____________________
Print Name of Person Making Request
Signature of Person Making Request
Phone No.
Fee for use of Facility ..............................$ _____________
or Costs Charged to Code ____________________________________
Auditorium ................................................$ _____________
Approved Disapproved
Pool ...........................................................$ _____________
Gymnasium ...............................................$ _____________
Fee for use of Special Equipment .............$ _____________
__________________________________________________
Community Education Coordinator Signature
Total ..$ _____________
0.00
Community Education Office Use Only
Approved Disapproved
Cash
Check #____________
__________________________________________________
Amount: $______________ Date: ________________
Principal Signature
Comments: __________________________________________________________________________________________________
____________________________________________________________________________________________________________
WHITE: Community Education Director
BLUE: Building Engineer
GREEN: Organization / Individual
PINK: Building Principal
Form 1130
(Rev. 4/04) w 1M
Item #35-05-001025
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