905.1E1 - Community Use of School Facilities and Equipment Request Form

Facility/Equipment Requested:_______________________________________________

Date of Event:_____________________________ Alternate Date:__________________

Set Up Time:______________ Start Time: _______________End Time: ____________

Group Title: _______________________Purpose of  Activity:_____________________

Admission charged? ___Yes ___No  ________Amount____________ For Profit? _____

Contact Person: ______________________________No. people expected ___________

Address:   ________________________________     ____________________________

Phone: (Business) _______________________  (Home) __________________________

Email Address: ___________________________________________________________                                                    

CUSTODIAL SERVICES NEEDED:   To Open ____  To Close ____ During use____

EQUIPMENT NEEDED:

_____ Bleachers                            _____ Lunch Tables                  _____Volleyball nets

_____ Chairs                                 _____Writing Tables                 _____ Basketball hoops

_____ Dressing Rooms                 _____Shower Rooms                 _____ Media Equip:

_____Microphones                        _____Podium                                          

_____Stage Lights                                                                                         

Other Notes:___________________________________________________________________
_____________________________________________________________________________

 

 

AGREEMENTS:

The undersigned, hereafter referred to as “entity,” agrees to the following:

AGREES TO OBSERVE THE TOBACCO/NICOTINE FREE AREAS AND NOT BRING ALCOHOLIC BEVERAGES OR ILLEGAL SUBSTANCES ON THE PREMISES.

AGREES TO PAY FOR ANY DAMAGES OCCURRING TO SCHOOL PROPERTY DUE TO YOUR USE OF THE FACILITIES.

AGREES TO NOT ALTER THE FACILITY IN ANY MANNER WITHOUT FIRST SECURING PERMISSION OF THE BUILDING PRINCIPAL OR HIS/HER DESIGNEE; AGREES TO ABIDE BY ALL TERMS AND CONDITIONS PERTAINING TO THE USE OF SCHOOL FACILITIES.

AGREES TO PROVIDE THE DISTRICT WITH A VALID CERTIFICATE OF INSURANCE NAMING THE RED OAK COMMUNITY SCHOOL DISTRICT AS AN ADDITIONAL INSURED WITH A MINIMUM OF $100,000 OF GENERAL LIABILITY.  (YOUR CERTIFICATE MUST BE SUBMITTED WITH THIS FORM SO THAT YOUR REQUEST CAN BE CONSIDERED FOR APPROVAL.)

AGREES TO HOLD THE DISTRICT HARMLESS AND INDEMNIFY THE DISTRICT AS OUTLINED IN ITS SIGNED INDEMNITY AND LIABILITY INSURANCE AGREEMENT.

 

SIGNED BY:                                                                            DATE:                                             

 

ACTING ON BEHALF OF THE FOLLOWING ORGANIZATION:                                            

PLEASE SUBMIT THIS FORM TO THE RED OAK COMMUNITY SCHOOL DISTRICT, ADMINISTRATIVE CENTER, 1901 N. BROADWAY ST STE A RED OAK, IA 51566.  PHONE:  (712) 623-6600; FAX:  (712) 623-6603