Facility Use Application School Site: Name of User/Organization FAX: TWO CONTACT NAMES REQUIRED (Include complete mailing addresses):
(Include area codes):
1. Name: Address: City, State, ZIP: 2. Name: Address: City, State, ZIP: Daytime phone: Evening phone: Daytime phone: Evening phone: Space(s) to be used: (ex: gym, auditorium, cafeteria) Equipment, if available, at additional cost: Number of persons expected (include audiences): Purpose: Amount charged by User for admission, entry, or class: Adults Children Exact date(s) needed, including specific month, day, year and time(s): (Attach additional schedule if needed)
Number of Days Example 1: Example 2: Totals: 5/6/06 Saturday Beginning Time 1:00 pm 5/6 & 5/13/06 Saturday 1:00 pm Date Day of Week Monday Tuesday Wednesday Thursday Friday Saturday Sunday Ending Time 6:00 pm 6:00 pm Total Hours Hours X Days 5 x 1 5 x 2 10 *I have read and agree to abide by Board Policy.
*I understand that the structure of this agreement is intended to define this activity as one “for other than school purposes” in accordance with the provisions
of G.S. 115C-524(b). Per said statute, “No liability shall attach to any board of education, individually or collectively, for personal injury suffered by reason of
the use of such school property pursuant to such agreements.”
The User/Organization is: (check one) □ Profit Non-­Profit ID # _______________________ □ Civic/Youth Organization * Signature of Applicant Date □ Sports/Dance groups: Certificate of Liability Insurance required & Roster PERSONNEL REQUIRED (check all appropriate): # hours □ Custodian □ Facility Supervisor □ Technical COMMENTS/Special Instructions: ATTACHMENTS: □ Cafeteria employee □ Other (specify) □ None (specify) # hours # hours # hours # hours # hours □ $25 Non-­Refundable Application Fee □ Additional charges / conditions □ Approved □ Not Approved Principal
Date
Executive Director of Auxiliary Services
Date
FACILITY USE RENTAL FEES
Minimum two-­hour charge per space per occurrence INTERIOR SPACE PROFIT (per hr.) NON-­PROFIT (per hr.) CIVIC/YOUTH (per hr.) Auditorium* $100.00 Conference Room * $20.00 Dining Hall (ONLY)* $60.00 Dining Hall + Kitchen* $100.00 + staff Gymnasium $100.00 Gymnatorium/ $100.00 Multi-­purpose Room $50.00 $25.00 $10.00 $5.00 $30.00 $15.00 $50.00 + staff $25.00 + staff $50.00 $25.00 $50.00 $25.00 EXTERIOR SPACE PROFIT (per hr.) & NON-­PROFIT (per hr.) CIVIC/YOUTH (per hr.) (TOURNEMENTS) Playgrounds Baseball Field Football Field Soccer Field No Charge No Charge $25.00 $12.50 $25.00 $12.50 $25.00 $12.50 No Charge $6.25 $6.25 $6.25 PERSONNEL PROFIT/NON-­PROFIT (2hr. min) EMPLOYEE PAY Cafeteria Emp. Custodian Technician $20.00 $20.00 $20.00 Time & Half Time & Half $15.70