ORGANIZATION: ____________________________________________________________________________
NAME OF REPRESENTATIVE: _________________________________________________________________
ADDRESS: ________________________________________________________________________________
TELEPHONE #: (HOME) ______________________________ (WORK) _______________________________
EQUIPMENT TO BE USED OR RENTED: ________________________________________________________
___________________________________________________________________________________________
DATE(S) OF USAGE:_________________________________________________________________________
TIME: _________________________________________________________________________(A.M. OR P.M.)
LOCATION: ________________________________________________________________________________
PURPOSE OF USAGE OR RENTAL: _____________________________________________________________
____________________________________________________________________________________________
IMPORTANT NOTICE: The above named group or individual agrees to reimburse the school for any damage to equipment. The reimbursement shall be determined by the River Valley School Board.
________________________________ ___________________________________________________
Date Requested Group Representative or Individual
___________________________________________________
Building Principal/Administrative Building Coordinator Approval
Copies of this form to be sent by Building Principal/Administrative Building Coordinator to:
1. Group Representative or Individual Requesting Use of School Equipment
2. District Administrator
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EQUIPMENT DESCRIPTION: __________________________________________________________________
MODEL #: _________________________________________________________________________________
RIVER VALLEY SCHOOL DISTRICT I.D. #: ______________________________________________________
APPROVED: July 13, 2000
12/21/2004 pw