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(Office Use Only)

Site ___________

Pleasant Valley School District

Schl Year __________ App#___________

Facility Use Reservation Application

Day __________ Reoccurring ______

khaws@pvsd.k12.ca.us

(805)445-8663

600 Temple Avenue, Camarillo, CA 93010

Assigned Sub(s):_____________________

__________________________________

___

Outside User Group

PVSD User____

Today’s Date: ___________________

Print Name of Applicant or Representative:______________________________________________________________

___

Print Name of Organization: __________________________________________ Activity_________________________

Are you a non-profit Organization? No____ Yes____ If yes, list 501c

#_______________________________ (please attach a copy)

Admission Charge / Solicitation? No____ Yes____ If yes, $__________ and/or Materials_________________________

Phone: ____________________ Cell Phone: ___________________ Email: __________________________________

Street Address: ______________________________________ City: __________________________ Zip: ___________

…………………………………………………………………………..……………………………………………………………………………………..………………..

FACILITY RENTAL INFORMATION

Estimated Maximum Attendance:_________________

1. Rental Date Requested: First Day of Event_______________________ Last Day of Event______________________

2. Total Days Requested: _______________________

(Please specify all dates & times on Facility Use Reservation Calendar)

Camarillo Heights

Dos Caminos

El Descanso

Las Posas

3. Facility Requested:

(Please check a box):

 La Mariposa

Los Primeros

Ranch Rosal

Santa Rosa

Tierra Linda

Las Colinas

Monte Vista

PVIC – Field only (User group must provide portable restrooms) Other: ___________________________________

 MPR

 GYM

FIELDS

 LUNCH SHELTERS

PARKING LOT

4. Location(s) on Site Requested:

 LIBRARY

CLASSROOM(s)____________________________

Los Altos (UCMS)

 University Prep (UPS)

5. Special Request: Restrooms: No _____Yes _____

(Restrooms will be required if event exceeds 2 hours)

Based on availability at the site: Podium: No _____Yes _____

Chairs#_____________ Benches#_____________

Table w/bencher #_______ 6 ft. Table# ________ Other:__________________________________________________

6. Special Instructions: _____________________________________________________________________________

_____________________________________________________________________________________________________________________________________

(Do Not Write Below - Civic Center Office Use Only)

…………………………………………………………………………..……………………………………………………………………………..……………………….

Application Completed: No ____Yes ____

Statement /Application/Calendar/Diagram) Liability Insurance: No ____Yes ____ Expires: _________

(

Principal/Site Approved: No _____Yes _____

Site Dates Unavailable: ____________________________________________________________

Date: ____________

Approved/DO: _______________________________ No_____ If no, state reason:________________________________

Application Fee

_______ Total Days:________ Total Hrs _________ Rental/Use Fee (hour or day

:_______ Restrooms

________

($25)

)

($15 per day)

Custodian

_____________ Student Helper:

_____________ Floor Maintenance Gym/MPR

_____________

($30 hr/2 hr min)

($9hr/2 hr min)

($3.50 hr)

(Civic Center Office Use Only - Application Notification Progress: District ______ FMO______ Site ______ Applicant ______ Sub______ Billing______)

Rev. July 17, 2014

Page 2 of 4

Form 1330 E-2 - Application And Agreement For Use Of School Facilities - Pleasant Valley School District - 2014 Page 2

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