905.1E1- Request for Use of School District Building and Equipment

Directions:   This form is to be completed by the community adult requesting use of a district building and/or equipment a minimum of three (3) days prior to the date the building and/or equipment is to be used.  Please complete the form in full.  If you have questions, the superintendent or secretary will assist you.

 

1. Date of Request – today’s date.                                                                                                    
2. Date use of Building/Equipment is desired.               ______________________________
3. Estimated time of use on the above date.                       ______________________________
4. Building name and area within the building.                    ______________________________                                                                                               
5. School district equipment desired.                                     ______________________________
6. Purpose for desiring to use the building and/or equipment – please describe in detail.   
           __________________________________________________________________________________
           __________________________________________________________________________________
7. Name of person completing this form.    __________________________________________________    
8. Name of group you represent.   _________________________________________________________

 

PERSONAL LIABILITY

I acknowledge that I am to be considered personally liable for the use of the building and/or equipment and for the activity to occur within the building as described above.  Should any damage to the building and/or equipment occur as a result of the activity described above I agree to assume personal liability for such damage and agree to pay the district for any necessary repairs or replacement of equipment, etc. as deemed appropriate by the district.

 

 ________________________________       _______________         ___________________________
Signature                                                                                         Date                               Phone Number

 

 

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The following section is to be completed by the Superintendent or Designee

_____ Request approved                  ______ Request denied                    ______ Fee Charged

_____ A copy of the building use rules & regulations has been given to the individual.

_____ A key has been given to the individual requesting use of the building.

_____ Use fee has been paid in full _______________________________________
                                                                                               Date use fee paid

 

 

 

________________________________________________________                 __________________
Superintendent’s signature or Designee                                                                                                 Date

 

 

 

Approved 01-15-90                         
Reviewed 08-18-03; 01-19-09; 08-10-16
Revised 09-17-03