Request for use of School Facilities

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SULLIVAN WEST CENTRAL SCHOOL DISTRICT

PO BOX 308

Jeffersonville, NY 12748

Office: (845)482-4610 Fax: (845) 482-4620

REQUEST FOR USE OF SCHOOL FACILITIES

All requests to schedule events in the Sullivan West Central School District must be submitted to the Student Services office in writing on this form as soon as possible, but not less than 2 weeks prior to the event. The Student Services office will forward this form to the Building Principal. This request is not approved until you receive an emailed copy signed by the District. if you have any questions, please call (845) 482-4610 Ext. 3009.

ORGANIZATIONAL INFORMATION - Sponsoring Organization*

Answer required for "ORGANIZATIONAL INFORMATION - Sponsoring Organization"

This is a(n): (Please check all that are applicable)*

Answer required for "This is a(n): (Please check all that are applicable)"

SCHOOL ACTIVITY

NON-SCHOOL GROUP: (Insurance Certificate Required, please attach)

USE OF GYMNASIUM / ATHLETIC FIELDS — Athletic Director Approval

USE OF KITCHEN — Food Services Supervisor Approval

Contact Person

First Name

Answer required for "First Name"

Last Name

Answer required for "Last Name"

Answer required for "Email "

Phone

Number Required

Are you or another Chaperone AED/CPR Certified?

Answer required for "Are you or another Chaperone AED/CPR Certified?"

Yes

Name of Chaperone:

Answer required for "Name of Chaperone:"

EVENT INFORMATION

Name/Type of Event:

Answer required for "Name/Type of Event:"

Date(s)

Answer required for "Date(s)"

Beginning Time

Answer required for "Beginning Time"

Ending Time

Answer required for "Ending Time"

Estimate Number in Attendance

Answer required for "Estimate Number in Attendance"

Number of Adult Chaperones

Answer required for "Number of Adult Chaperones"

Area/Room Being Used

Answer required for "Area/Room Being Used"

CUSTODIAL or SPECIAL SERVICES REQUESTED:

Do you need custodial service for your event: (set —up, cleaning, etc.):

Answer required for "Do you need custodial service for your event: (set —up, cleaning, etc.): "

Yes

If Yes, please explain

Answer required for "If Yes, please explain"

If no custodian is requested, please indicate who will be responsible for clean-up:

Answer required for "If no custodian is requested, please indicate who will be responsible for clean-up:"

SET UP DATE

Set Up Time (if you need to come early)

Answer required for "Set Up Time (if you need to come early)"

SCHOOL BUILDING (CAMPUS) TO BE USED (Please check all which apply):

Answer required for "SCHOOL BUILDING (CAMPUS) TO BE USED (Please check all which apply):"

High School

Elementary School

The district, when necessary, will pay the custodian or district employee at the prevailing wage rate for clean-up. Your group will be expected to reimburse the district for the sum of these wages and applicable benefit costs ($41 to $52 per hour).

| have read all the policies and requirements below and agree to abide by them.

Do you intend to charge an admission fee during your proposed use of the District’s facilities?*

Answer required for "Do you intend to charge an admission fee during your proposed use of the District’s facilities?"

Yes

If yes, you must verify, by signing the signature line that follows, that the entire proceeds (l.e., “gross” proceeds, not “net”) from any admissions fees collected, will be expended for a non-profit “educational” or “charitable” purpose. Further, you must agree to submit to monitoring, by school officials, of the collection of admission fees during your organization's use of the District's facilities, and you must agree to submit to the School District's audit and inspection of the sums collected, and all related books, papers and documents pertaining to the admission fees collected during your organization’s use of the School District’s facilities.

l agree to the foregoing requirements:

Print Name*

Answer required for "Print Name"

Emergency Phone Number*

Number Required

Signature*

Signature Required

Requestor does covenant and agree to defend, indemnify and hold harmless the Sullivan West Central School District and against any and all liability, loss, damages, claims or actions (including costs and attorney’s fees) for bodily injury and/or property damage, to the extent permissible by law, arising out of or in any way connected with the actual or proposed use of Sullivan West Central School District’s property, facilities and/or services, including but not limited to bodily injury to any employee, invitee, guest, contractor or subcontractor of Requestor. Requestor understands and agrees that its use of Sullivan West Central School District’s property and facilities includes, but is not limited to, all areas identified in the application and/or permit, and sidewalks, walkways, parking lots, entrances, stairs, and all other areas incidental to and/or connected with the use of the premises

(hereinafter referred to as “incidental areas”). Requestor agrees that its indemnity and insurance obligations extend to the areas identified in the application and/ or permit and any and all incidental areas.

POLICY 3280 - COMMUNITY USE OF SCHOOL FACILITIES

The Board of Education recognizes and affirms that the primary purpose of school facilities is to provide and promote the education of the District’s children. The Board of Education encourages the use of school facilities by District residents and not-for-profit organizations which are educational, cultural, social, recreational or civic in nature.

Education Law Section 414 POLICY 3281 - USE OF SCHOOL OWNED MATERIALS AND EQUIPMENT EXCEPT WHEN USED IN DIRECT CONNECTION WITH OR WHEN RENTED UNDER PROVISIONS OF Education Law Section 141, school-owned materials or equipment may be used by members of the community or by District employees and/or students for school related purposes only. Private and/or personal use of school-owned materials and equipment is strictly prohibited. Any exceptions should be referred to the Superintendent of his designee.

Education Law Section 414 FACILITY USE FEE SCHEDULE Fees:

$41 - $52 per hour based on the custodial staff normal workday or overtime

$5 ROOM ONLY per room, per event (during normal workday of our custodial staff)

FREE ROOM ONLY (during the school day)

$15 Flat fee for event (for use of fields /grounds)

DISTRICT USE ONLY:

APPROVALS:

Building Principal: ___________________________________ Date:_______________________

Director of Facilities: _________________________________ Date: ______________________

Business Manager: _________________________________ Date: _______________________

Please fix the highlighted areas below before submitting.

Request for use of School Facilities