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
