Application For Use Of School Facilities Form
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1Revised 11/12/12
Halifax County Public Schools
1030 Mary Bethune Street, P. O. Box 1849
Halifax, VA 24558
APPLICATION FOR USE OF SCHOOL FACILITIES
APPLICANT IS TO COMPLETE ITEMS 1-10
Date application submitted_____________
1. Name of organization__________________________________________ Telephone number____________________
2. Address_____________________________________________________ Fax number_________________________
3. Name of applicant_____________________________________________ Telephone number____________________
4. Address__________________________________________________________________________________________
5. Facility to be used______________________________________ Dates________________ Time_________________
6. Purpose for which facility is to be used__________________________________________________________________
_____________________________________________________________________________________________________
7. Area(s) required
_____
Cafeteria
_____
Auditorium
_____
Classroom (please specify below)
_____
Kitchen
_____
Gymnasium
_____
Other (please specify below)
_____________________________________________________________________________________________________
8. Amount of admission to be charged_________________
Profits will accrue to___________________________
9. For participant use only
Yes
No
If Yes, maximum number of participants __________________
10. I certify that I am the duly elected or appointed representative of the organization aforementioned and have the authority to
reserve the school facilities for use by this organization. I do further agree to be severally and jointly responsible for any
damage that may occur to the school property, furniture, or equipment during the use for which this application is being
made and will save the School Board harmless from any liability that results from said use. I further agree to be
responsible for the maintenance of good order and conduct on school property.
____________________________________________
Signature of Applicant
---------------------------------------------------------------------------------------------------------------------------------------------------------
SCHOOL PRINCIPAL IS TO COMPLETE ITEMS 11-16
11. The facilities requested above are available on the date and time requested
Yes
No
12. Supervisor to be assigned____________________________________________
Total supervision hours__________
13. Custodian to be assigned_____________________________________________
Total custodian hours____________
14. Classification of user___________________________________ 14. Category of event__________________________
15. Additional comments_________________________________________________________________________________
______________________________________________________________________________________________________
16. Special conditions attached
Yes
No
Include stipulations, restrictions, or building use policy as part
of the application.
____________________________________________
Signature of Principal
---------------------------------------------------------------------------------------------------------------------------------------------------------
SCHOOL DIVISION ADMINISTRATION USE
Application is [ ] Approved
[ ] Disapproved
Comments___________________________________________
Certificate of insurance required
[ ] Yes
[ ] No
If yes, date received____________________________
Fees to be charged
Rental ___________
Supervision___________
Other____________
User_____________
Custodian____________
____________________________________________
Signature of School Division Administrator
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