HCCSC FACILITY PERMIT FOR USE OF SCHOOL PROPERTY

7510 F4/ page 1 of 3

HUNTINGTON COUNTY COMMUNITY SCHOOLS
FACILITY PERMIT FOR USE OF SCHOOL PROPERTY

Please complete the first portion of the request form and sign the bottom that the form is complete and you have read the administrative guidelines and associated fees. The form will then be submitted to our building principal for approval and to the district office for review by the Superintendent. Once the fees have been estimated a copy of this form will be emailed to you for your review. Before you are permitted to use the facility you must sign this form acknowledging the estimated costs that you will incure for the use of a facility. You must sign the form and submit again. All requests must be submitted at least three (3) weeks prior to the anticipated date of use.
Name of Organization
Event Name
Contact's Email Address
example@example.com
Date of Submission

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HCCS Facility Requested School Name or District Office Building (If multiple, please fill out a form for each building.)
Area Desired

Other
Rooms (list all rooms if not listed above)
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Cell Phone)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Work Phone)
Please enter a valid phone number.Format: (000) 000-0000.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Event

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Event request must be three weeks in advance.
Will this event be for more than 1 day?
*If multiple dates are being requested please create a document with additional dates and times listed and upload the document below.
Please list Multiple Days Requested below:
Multiple Days Requested Attachment:

Cancelof
Start Time of Event:

Hour Minutes

AM/PM Option
End Time of Event:

Hour Minutes

AM/PM Option
What time will building need to be open?

Hour Minutes

AM/PM Option
What time will you leave the building?

Hour Minutes

AM/PM Option
Number Attending
What is needed for your event?

Other
Will an admission fee be collected for this event?
If yes, what is the anticipated gate fee?
Are you an HCCSC Employee?
HCCSC Employee On-Site Point of Contact (When no custodian is on duty)
HCCSC Employee Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Click link to view the Policy Manual for Use of School Facilities code:7510

https://go.boarddocs.com/in/hccsc/Board.nsf/goto?open&id=BLAHKP48DCA8

I have read and understand HCCSC Administration Guidelines and associated fees for Facility Use Policy number 7510: (please sign below)
Name of Representing Group
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Organizations requesting to use our facilities will be required to provide a Certificate of Liability Insurance. Your insurance agent may be able to email a digital copy of your Certificate of Liability Insurance to you that can then be uploaded to this form. You may also take a photo of your Certificate of Liability Insurance and upload the photo.

Cancelof
School Office Use Only
Custodial Coverage Required?
If yes, Approximate number of hours needed for Custodial Coverage?
Are all dates requested approved?
If no, Please list the dates not available:
Signature of Principal
Principal Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Athletic Director if necessary
Athetic Director Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date Received

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Central Office Use Only
Comments
Denial Comments
Facility Estimate Cost Statement:
* The amounts listed are only an estimate. A final invoice will be mailed after the event has taken place with actual facility hours used and actual personnel costs.
If you are requesting to use a facility for an extended period of time, spanning a month or more, you will be billed monthly for the Facility Use.

Total Cost Calculation:
Is the Certificate of Liability Insurance required for this request?
Is a fee to be applied for this Facility Use Agreement
Superindtendent Signature
Superintendent Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Facility Use Agreement
I have read and agree to the administration guidelines and the estimated fees associated with my group/events usage of the HCCSC Facility listed on the Facility use agreement. I understand that I will be billed after the use of the facility with the actual number of hours the facility was used for, along with any other required personnel charges.
Signature of Representative of Requesting Group
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
- Custodian Email
  example@example.com
- Date Calculate
- Text for admission fee being collected
- Principal Email
  example@example.com
- Athletic Director Email:
  example@example.com
- Secretary Email
  example@example.com
- Food Service Director Email
  example@example.com
- Food Service Secretary Email
  example@example.com
- Calculate Gymnasium
- Text Gymnasium
- Calculate Auxiliary Gym
- Text Auxiliary Gym
- Calculate Auditorium
- Text Auditorium
- Calculate Commons
- Text Commons
- Calculate Library
- Text Library
- Calculate Fieldhouse
- Text Fieldhouse
- Calculate Other
- Text Other
- Calculate Facility Rental Fee Total
- Text Facility Rental Fee Totals:
- Calculate Personnel Fee
- Text Personnel Fee
- Should be Empty:

Rows	Description	Cost Per Hour	Number of Hours	Personnel Cost	Line Total	Notes
Gymnasium
Auxillary Gym
Auditorium
Commons
Library
Fieldhouse
Other
Personnel Fee Total