R

 

EQUEST FOR USE OF SCHOOL FACILITIES

 

BUILDING REQUESTED:_____________________________________

 

Gymnasium______ Cafeteria______ Classroom______ Kitchen______

 

Grounds/Field Use (specify area requested)_______________________

 

Custodial hourly rate per person: $18.00

 

Snow Removal ho urly rate per person: $18.00

 

Kitchen coverage hourly rate per person:

$16.95

 

Estimated Number of Participants:______________________________

 

Name/phone # of responsible adult who will be present at all times:___________________________

 

Equipment Requested (if any)__________________________________________________________

 

 

NAME OF ORGANIZATION__________________________________________________________

 

ADDRESS___________________________________________________________________________

 

PURPOSE___________________________________________________________________________

 

Is an admission fee charged? Yes___ No___ (If yes, specify the educational, civic or charitable

function it will support)________________________________________________________________

 

I, the undersigned, as the authorized representative of the organization making this request understand all of the

District’s policies and regulations governing Public Use of School Facilities and agree that we will abide by them

(see attached). This organization agrees to hold harmless the Wayne Central School District against any claims

for both property damage and bodily injury arising from this event.

 

Person in Charge___________________________ Signature________________________________

 

Address__________________________________ Phone (h)______________ (w)_______________

 

__________________________________ Date Form Submitted______________________

  

?

School activities shall take precedence over all other uses.?

 

DAY OF THE WEEK

 

M T W Th F S S

 

 

Please circle day(s)

 

DATES REQUESTED:

 

From_____/_____/_____

 

TO______/______/_____

 

HOURS OF USE:

 

From___________a.m./p.m.

 

TO_____________a.m./p.m.

 

Has the Certificate of Insurance naming WCSD as an additional insured been received and approved? YES___ NO___

 

I recommend approval: Athletic Director________ Director of Facilities________ Food Service Supervisor_______

 

APPROVED:_______________________________________, Building Principal DATE:________________________

 

Distribution:

Applicant

Building Custodian

Director of Facilities Building Cafeteria

Athletic Director

Building Principal Other_________________________________________

FOR SCHOOL USE ON

FOR SCHOOL USE ON

FOR SCHOOL USE ON

LY

LY

LY

 

 

 

2002

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2003