HomeMy WebLinkAboutGreater Clark County Schools02/19(2008 12:38 2856903 ~~~PAGE 02
GREATER CLARK COUNTY SCHOOLS I ~ V I O ~~
2718 E. Tenth Street, Jeffersornille, Indiana 47130 ~ Y /- ! /g,
(872)268-4821 ~/
FACILITIES USAGE APPLICATION
Name of Organization 1~'
Area Desired
'r~~V List all rooms and/or areas requested c 1 ~
Date(s) of Event l .S Number of Hours a '1a 1,Ote'S ~W'ry
Time Doors Open -..-.,,,_yvAM Time PoprS Close gFY11__ L`4n_ rlf~ ~a ACCYI
Dafe(S) of REhe9rsel Number of Hour9
Time Doors Open Time Oaors Close
If usage is for a season or an extended perloQ Ilst frequency (day[s] of weeN) end beginning/ending dates:
Nature of Program anr,eca-F-M Tn~fYrFICt-hrMl VhP P4ifY'
Proceeds for Benefit of
Special Equipment Oesiretl I
Is heating or air conditioning required? as No CWJ-fC(t~2(~)
_ For non-0005 sponsored groups, a copy of the organization s ion-proft certifcate', if applicable, and liability
ineuranee cerHFlcate in the amount of $1 million are required and attached. Check here if forms ere
already on fie in the Auxiliary Services Office.
"Organizations that are not non-profit must meet the condition6 of Policy 1330, # 10 through # 12.
For swimming pool usage, a certified lifeguard must be in attendance at ali times. A rgpy of the lifeguard's
certificaiien is required and attached.
For student participant groups', Group is composed of al least 90°h GCCS students.
Group is composed of at least 51%GCCS students.
/ Group is composed of less then 50%GCCS studems.
Applicant will _ will not r! charga an admission fee. Expected attendance is approximately ~ persons-
APPLICANT ACKNOWLEDGEMENT:
We nave read end fully understand the rules end regulations of the board of School Trustees governing the use of these
facilities as listed in Policies 1330, 1330.1, and Fee Schedule previously received/reviewed. We agree to the strict
observance of these rules and regulations, and to be responsible for any damage to school property due to such use.
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02/19/2008 12:38 2856403
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FACILITIES USAGE APPLICATION
PAGE 03
BUILDING LEVEL APPROVAL
The applicant meets the eligibility requirements and the intended use is in dance with School Board Policies.
Prescribed fees will be collected and this request is duly approved pending authorization from the Auxiliary Services
Office,
Thia even[ iS le not
AUXILIARY SERVICES OFFICE
$ ~F Estimated Total Fee. Includes fees for custodial and cafeteria personnel, building equipment, etc.
Additional personnel and quantity required Por event (schedufng and wst of personnel is the responsibility of the
appl ice nt/organizationp
seounry ofhcers(s),
parking Ict atlendarn(s),
other
Final billing will be made to the applicant after the conclusion of the activity. Make check payable to: Greater Clark
County Schools.
CiUSlL~ I+YI_ tFE E ~ ~a7. (/ ~~~ Fees assessed and permit authorized in accordance with rules
I wU 2 Fn (Z SAT, ~ .3 ~2Z~U $ and regulations of the Board of School Trustees.
~fGNTI $ODU1~ I~CfF j0 8£
AK/L4NGf.~ -(tiRouGN ~}S, e' a o~~ 0$/
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ADMINISTRATIVE APPROVAL (FOR PROFIT ORGANIZATIONS)
The applicant has demonstrated that it meets the conditions of Policy 1330, # 10 through #12.
aapetlntenrlant
cc: Office File
Building Principal
Facilities supervisor
Energy Manager
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