Facility Requested:

  

  

  

  

  

  

  

Area(s)/Room(s) Requested:

 

 

 

Organization Requesting Use:

Address:

 

  

  

  

  

  

  

  

  

  

  

  

Tax Exempt #:

  

  

  

  

  

  

  

  

Organization Contact:

Daytime/Cell Phone:

E-Mail Address:

On Site Adult Responsible Contact:

  

Daytime/Cell Phone:

  

 

 

   

Date(s) Requested:

  

Time(s) Requested:

  

Activity Description:

  

Estimated # of Participants:

Room Setup:

  

                     

  

 

 

  

  

Estimated Fee

Number of hours of use:

            

hours

  

Hourly rate:

            

per

hour

Custodial Personnel Fee: $25.00

            

hours

Kitchen Personnel Fee: $25.00

            

hours

Security Personnel Fee: $25.00

            

hours

Damage Deposit: (if required)

            

  

Special Equipment Fee:

            

  

 

  

  

   

 

  

REQUEST FOR

COMMUNITY USE

OF SCHOOL FACILITIES

Facility

Information

User Organization

Information

Schedule

Information

Fee Information

---

I,

, whose signature

appears below, am authorized to act as the legal agent of the above named organization

(applicant) for the purpose of application for and use of the Douglas County School

District’s facility referenced above. I acknowledge receipt of Board of Education Policy

KF, and Regulations KF-R2, and agree to the conditions of building use as specified

herein.

 

The applicant agrees that it shall be responsible for the conduct and control of all

participants and spectators, and shall ensure that use of the above referenced facility is in

compliance with all applicable federal, state, municipal, and School District safety

regulations. The applicant agrees to provide adequate adult supervision during the use of

the facility.

 

The applicant recognizes that the School District’s property and general liability

insurance policies do not provide coverage to organizations using school facilities for

non-school activities. The applicant is required to provide a certificate of comprehensive

general liability insurance in the amount of $1,000,000 per occurrence. The certificate of

insurance must have an endorsement naming Douglas County School District RE. 1 as an

additional insured as it’s interests may appear.

 

In consideration of the applicant’s use of the School District’s facilities, the applicant

agrees to indemnify, defend and hold harmless the School District, its respective agents,

affiliates, officers, directors, servants, and employees of and from all loss, cost damage,

injury, liability, claims, liens, demands, actions, and causes of action whatsoever arising

out of, or related to applicant’s negligent or intentional acts, errors, and omissions or

those of its employees, agents and participants in connection with the use of the School

District’s facility.

 

For the safety of our students, staff and visitors, security cameras may be in use at any

time. Smoking and tobacco use in all school district buildings and on all school campuses

is prohibited at all times. For additional information or to report violations, please call

District Security at 303-387-9999.

 

 

 

 

 

 

 

 

 

 

 

 

 

             

        

  

Applicant Signature Date

             

        

  

Facility Use Coordinator Signature Date

Request

Approved

Request Denied