Application For Use Of District Facilities/property Form
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2707. APPENDIX A
POCONO MOUNTAIN SCHOOL DISTRICT
APPLICATION FOR USE OF DISTRICT FACILITIES/PROPERTY
Date: _____________________________
Contact email:__________________________
Name of Organization/Individual: _________________________________________________________
Name of Contact: _______________________________ Telephone#: ___________________________
Address: ______________________________________ Home/Business: ________________________
Facilities/Property Requested: ____________________ School: _______________________________
Dates/Days Requested: _________________________________________________________________
Time Requested: _______________ AM/PM
to _______________ AM/PM
Purpose of Facilities/Property Usage: ______________________________________________________
# of Persons Attending: _______________ # of Persons Supervising Activity/Event: ________________
Age of Participants: __________________
Participants are: District Residents/Out-of-District Residents/Combination
Equipment Requested:
Tables/Chairs
#: _____________________
Kitchen Equipment
Type/#: ________________
Other Equipment
Type/#: ________________
Requested District Personnel:
Custodians
Yes
No
Security
Yes
No
Cafeteria Assistants
Yes
No
Local/State/National Affiliations:__________________________________________________________
Staff Criminal History Checks/Clearances Available:
Yes
No
Concessions: Food/Non-Food Items: _______________________________________________________
Registration Fees/Entry Fees/Ticket Sales: __________________________________________________
Insurance Information: _________________________________________________________________
(Attach Copy of Insurance Certificate)
Signature of Applicant: _________________________ Title: ____________________Date: ___________
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Parent category: Business