NOTE: Read “Facilities Use Regulations” on the back of this form before completing this form.
* Name of Individual/Group:_________________________________________________________________
Name of Group Representative:_____________________________________________________________
Address:____________________________________________________________________________
Telephone Number:___________________________________________________________________
* Facility Requested:______________________________________________________________________
Date(s) of Usage:_____________________________________________________________________
Time of Usage (note a.m. or p.m.):_______________________________________________________
Purpose of Usage:________________________________________________________________________
Equipment to Be Used or Rented: ______________________________________________________
* Will an admission fee be charged? ____YES _____NO
* Do you need keys/security code for gaining entrance to the building? ____YES _____NO
Comments: ________________________________________________________________________
I hereby agree that I understand the following:
Liability Insurance - The school district does not provide insurance for this use. I/We must provide insurance to insure that I am/we are protected against liability.
Damage Reimbursement - I/We must reimburse the school for any damage to equipment, chairs, furniture, building, etc. The reimbursement shall be determined by the River Valley School Board. Depending on the extent of damages, there is the potential denial of future use.
Prohibition of Alcohol/Tobacco - Use of tobacco, alcohol, or any controlled substance is prohibited in all school facilities, school vehicles, and all school premises.
Clean-Up - I/We must clean up the facilities used or I/we may be charged for clean-up. Clean-up includes checking restrooms for cleanliness or misuse, turning off lights and heat, and securing/locking building. Additionally, all materials brought into the building must be removed at the conclusion of use.
_________________________________________ _____________________________
Signature of Individual or Group Representative Date
TO BE COMPLETED BY BUILDING PRINCIPAL/ADMINISTRATIVE BUILDING COORDINATOR:
_____ Approved _____ Denied * Rental Fee: $________________
Comments:___________________________________________________________________
____________________________________________________ ______________________
Signature of Building Principal/Administrative Building Coordinator Date
Copies of this form to be sent by Building Principal/Administrative Building Coordinator to:
1. Individual or Group Requesting Use of School Facilities
2. District Administrator
3. Athletic Director (if facility requested is a gym)
REVISED: March 12, 1998 * See #10. Fee Schedule on the back of this form.
APPROVED: March 26, 1998
REVISED: June 8, 2000
APPROVED: July 13, 2000
APPROVED: October 21, 2004
12/21/2004 pw