Facilities Use Form

SHENENDEHOWA CENTRAL SCHOOL DISTRICT

Clifton Park, NY 12065

Revocable License for Facilities Use

                                                                                                                        Event # ___________

TO BE COMPLETED BY THE APPLICANT:

Organization Name _______________________________ Contact Person: _____________________

Phone Numbers: Home ____________________Work ________________ Cell __________________

Billing Address ________________________________________ Email _______________________

City ________________________________            State __________       Zip Code ___________________

Description of Event _________________________________________________________________

Number of Participants ______ # of Shenendehowa Residents ______ Admission Fee? ______           

 

Building Requested: ____________________________

Classroom(s) _____________________Gym _______        Cafeteria ______________Pool ______

Auditorium ___________Field(s) ________________        Stage _____    Other _________________

 

Specific Dates Requested:     Start Date _________             End Date _____________

 

Day                                         Dates                                      Beginning Time          Ending Time

Sunday            _____________________________              _____________            ____________

Monday           _____________________________              _____________            ____________

Tuesday          _____________________________              _____________            ____________

Wednesday     _____________________________              _____________            ____________

Thursday         _____________________________              _____________            ____________

Friday             _____________________________              _____________            ____________

Saturday          _____________________________              _____________            ____________

Canceled Dates _____________________________________________________________________

 

Other Needs:

A/V Equipment                  Yes ____ No___                                             Cooking/Equipment          Yes _____               No _____

Specific Table/Chair Set Up           Yes ____ No___                              Diagram                                            Yes _____    No _____

Security Personnel                           Yes ____ No___                              Other ________________________________

Explanation of Needs: _____________________________________________________________________________

_______________________________________________________________________________________________

# of parking spaced needed _____                             Insurance on file:              Yes _____           No _____               Attached ___

Diagram of set up attached?                          Yes _____           No _______

 

Agreement: The applicant(s) agree to be bound by all rules, regulations, and requirements, including those related to insurance and indemnification, contained in the Use of Facilities Handbook (receipt of which is hereby acknowledged.)  The applicant also agrees to assume all financial responsibility for all and any damage done to school property during the above indicated period of use.  The applicant also understands that all school programs are given first priority in use of facilities and as a result, an applicant activity could be canceled and/or rescheduled because of a school activity/program.

 

Signature of Applicant ___________________________________________________        Date ____________

 

 

TO BE COMPLETED BY THE DISTRICT:

Group Classification _______                                   Security Deposit _________

Hourly Room Rental rate $________                                    Custodial Cost (if applicable) $ __________

Special Event Fee $ _____________

 

Administrator’s Signature ___________________________________________  Date ________

 

An approved copy of the School license form is proof that reservations and arrangements have been made with the appropriate school officials for use of facilities.

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