REQUEST FOR USE OF BENEWAY HIGH SCHOOL

 

 

 

NAME OF ORGANIZATION__________________________________________

 

EVENT:_____________________________________________________________

 

Estimated # of Participants:___________ Estimated Audience Size:__________

 

Snow Removal hourly rate per vehicle: $18.00

 

Custodial Hourly Rate Per Person: $18.00

 

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

___________________________________

 

Technical Assistance Hourly Rate Per Person: $15.00

 

Audio Needs:________________________________________________________________________________

 

Lighting Needs:______________________________________________________________________________

 

Video Needs:________________________________________________________________________________

 

Pit Floor

:___________________________________________________________________________________

 

Other :_____________________________________________________________________________________

 

             

______________________________________________________________________________________

 

 

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, regula­

tions and requirements governing 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_______________________

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 Certificate of Insurance naming Wayne Central School District as additional insured been received /approved? YES____ NO____

 

APPROVED:_____________________________________, Building Principal DATE:________________________

 

Distribution: Applicant Building Custodian Director of Facilities Cafeteria Supervisor Technology Dept.

 

Principal Music Dept. Audio Technicians Other:___________________________________

FOR SCHOOL USE ONLY