A	B	C	D	E	F	G	H	I	J
1
2					REQUEST FOR
3					COMMUNITY USE
4					OF SCHOOL FACILITIES
5	Facility		Facility Requested:
6	Information		Area(s)/Room(s) Requested:
7
8
9			Organization Requesting Use:
10				Address:
11
12	User		Tax Exempt #:
13	Organization		Organization Contact:
14	Information			Daytime/Cell Phone:
15				E-Mail Address:
16			On Site Adult Responsible Contact:
17				Daytime/Cell Phone:
18
19
20			Date(s) Requested:
21			Time(s) Requested:
22	Schedule		Activity Description:
23			Estimated # of Participants:
24	Information		Room Setup:
25
26
27
28									Estimated Fee
29			Number of hours of use:					hours
30			Hourly rate:					per hour		$0.00
31			Custodial Personnel Fee: $21.00					hours		$0.00
32	Fee		Kitchen Personnel Fee: $21.00					hours		$0.00
33	Information		Security Personnel Fee: $21.00					hours		$0.00
34			Damage Deposit: (if required)							$0.00
35			Special Equipment Fee:							$0.00
36
37			Total Payable at Time of Approval							$0.00
38
39
40
41	I						,	whose signature
42	appears below, am authorized to act as the legal agent of the above named organization
43	(applicant) for the purpose of application for and use of the Douglas County School
44	District’s facility referenced above. I acknowledge receipt of Board of Education Policy
45	KF, and Regulations KF-R2, and agree to the conditions of building use as specified
46	herein.
47
48	The applicant agrees that it shall be responsible for the conduct and control of all
49	participants and spectators, and shall ensure that use of the above referenced facility is in
50	compliance with all applicable federal, state, municipal, and School District safety
51	regulations. The applicant agrees to provide adequate adult supervision during the use of
52	the facility.
53
54	The applicant recognizes that the School District’s property and general liability
55	insurance policies do not provide coverage to organizations using school facilities for
56	non-school activities. The applicant is required to provide a certificate of comprehensive
57	general liability insurance in the amount of $1,000,000 per occurrence. The certificate of
58	insurance must have an endorsement naming Douglas County School District RE. 1 as an
59	additional insured as it’s interests may appear.
60
61	In consideration of the applicant’s use of the School District’s facilities, the applicant
62	agrees to indemnify, defend and hold harmless the School District, its respective agents,
63	affiliates, officers, directors, servants, and employees of and from all loss, cost damage,
64	injury, liability, claims, liens, demands, actions, and causes of action whatsoever arising
65	out of, or related to applicant’s negligent or intentional acts, errors, and omissions or
66	those of its employees, agents and participants in connection with the use of the School
67	District’s facility.
68
69	For the safety of our students, staff and visitors, security cameras may be in use at any
70	time. Smoking and tobacco use in all school district buildings and on all school campuses
71	is prohibited at all times. For additional information or to report violations, please call
72	District Security at 303-387-9999.
73
74
75	Applicant Signature							Date
76
77
78	Facility Use Coordinator Signature							Date
79
80	Request				Request
81	Approved				Denied