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.
- Date of Request – today’s date.
- Date use of Building/Equipment is desired. ______________________________
- Estimated time of use on the above date. ______________________________
- Building name and area within the building. ______________________________
- School district equipment desired. ______________________________
- Purpose for desiring to use the building and/or equipment – please describe in detail.
__________________________________________________________________________________
__________________________________________________________________________________ - Name of person completing this form. __________________________________________________
- 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
