Questions on the need to use this form? Email [email protected] at the SRU Sustainability Office!
LAND USE PROJECT REQUEST FORM
SLIPPERY ROCK UNIVERSITY
Requested by (Name)
Department/Budget Unit/Sponsor (Name)
College/Division (Name)
Title of Requester
Fund
Fund Center
Telephone Number
SECTION I - PROJECT INITIATION REQUEST
PROJECT TITLE AND DATE(s):
Installation of “SRU Recycles” Banner at Stores Building
DATE: December 2015
A.
Purpose of Request (check all applicable categories)
Permanent Change in Use of Land
Remove, Replace, or add Trees/Vegetation
Temporary Use of Land
Install Permanent Structures, Signage, Paths,
Walks, Roadways, Lighting, Trash Receptacles, etc.
Install Temporary Structures, Signage, etc.
Please provide the following information as appropriate, and attach campus map with affected land area
outlined (please note environmentally sensitive areas on campus grounds map):
1. Land/Lot/Property Name
___________________
2. Map Coordinates of Land
_________ or Mark up attached campus map
3. Current Area (acres)
_______________
__________
4. Proposed Area(acres)
_______________
5. Current Land Use
________________
ProposedLand
LandUse
Use
6. Proposed
7. Proposed Land Use Project Cost $0 Source of Funds: ______
8. Proposed Land Use Annual Maintenance Costs $0 Source of Funds: __________
9. Will any vertebrate animals be used for educational or research purposes? ____
NOTE: If “Yes”, SRU’s IACUC (Institutional Animals Care and Use Committee) approval is
required BEFORE a Land Use Request Form will be reviewed. Go to IACUC’s website
http://www.sru.edu/academics/colleges/ches/pages/iacuc.aspx for further information and to obtain
the protocol form to be completed. IACUC review/approval process takes approximately 30 days.
10. Will any animals be involved for non-educational/research purpose?
____
Note: If “Yes”, please attach documentation verifying the animal provider is a licensed vendor
complying with all Animal Welfare Act and other federal requirements.
11. Will this land use require any legal agreements with outside entities? _____
If “Yes”, attach draft legal agreement including any public liability insurance requirements.
12. If the activity involves potential danger to students or the public, you must have all participants
sign the attached waiver of liability form; a group sign-in form is also attached for your use;
these forms also must be completed as part of the Land Use Request.
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13. For events requiring traffic control barriers, the person organizing the event must contact the
SRU Police (Kevin Sharkey, 724-738-6139), who will help plan the traffic control needs and
coordinate with SRU Facilities staff providing sawhorses for temporary road closures.
B.
Description of Project
The Department Head/Budget Unit Head/Student Organization Sponsor is responsible for providing a
brief description of the project/proposal. Show how the changes/additions will assist the organization to
better serve the intended audience (e.g., students, faculty, staff, community). Include any needs assessment
data supporting the request. Clearly state changes desired including any changes to existing structures,
signage, trees, plantings, waterways, etc. Include a copy of the Campus Grounds Map, with the proposed
land use area outlined on it, and all supporting documents with this form, including a description of any
potential impacts of the proposed land use (number of participants/spectators per event, number of events
per year, types of vehicles in use, if any, etc.):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________
SECTION I – PROJECT INITIATION REQUEST APPROVAL
NAME
E-MAIL ADDRESS
________________________________
_____________________________
Department/Budget Unit Head/Student
Organization Sponsor
SECTION II - PROJECT EVALUATION/IMPLEMENTATION APPROVALS
When you have completed the form, please save it as a document to your hard drive or diskette, naming it
appropriately. You may then e-mail the document as an attached file to [email protected]. Please DO
NOT embed the document into the body of your e-mail. Additional supporting documentation can also be
attached to this e-mail if it is in electronic format (on your computer somewhere). Your request will be reviewed
and forwarded to the appropriate University organizations for their recommendation. If any of these materials
(request form and/or supporting documents) are only available in hard copy, forward them to the Paul Scanlon of
the Sustainability Office (currently at the Maintenance Center) by campus mail.
You will be notified by e-mail as to the disposition of your request. Please note that, if this land use request is
approved and the project includes construction involving SRU maintenance crews or outside contractors, a separate
Space/Project Request Form must be used to obtain review/approval of the construction specifics.
SECTION III – PROJECT EVALUATION and/or IMPLEMENTATION APPROVALS
The President may solicit recommendations from the following groups or others, as appropriate:
Facilities & Planning
NAME
Scott Albert
Dallas Cott
SRU Police
Kevin Sharkey
Land Use Project Request Form
E-MAIL ADDRESS
[email protected]
[email protected]
[email protected]
PHONE
x 4342
x 2538
x 6139
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Environmental Zoning Committee
President’s Commission
On Disability Issues
President’s Commission
On Sustainability
Dean Denicola
[email protected]
Scott Albert
Paul Scanlon
[email protected]
x 2484
x 4342
[email protected]
x 4268
[email protected]
x 2479
IACUC
Simon Beeching
EH&S
Paul Novak
APPROVED BY:
NAME
______________________
President Cheryl Norton
[email protected]
x 2465
E-MAIL ADDRESS
PHONE
[email protected]
724.738.2000
This document uses the Garamond font to save ink and paper; please print on both sides of paper if hard copies are needed!
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CAMPUS GROUNDS MAP – ENVIRONMENTALLY SENSITIVE AREAS
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Participant's name:
[Name
Please Print
]
SLIPPERY ROCK UNIVERSITY OF PENNSYLVANIA
[Name of class or activity]
Waiver of Liability, Assumption of Risk, and Indemnity Agreement
Waiver: In consideration of being permitted to participate in any way in
[Description of Class or Activity including date(s)]
hereinafter called "The Activity", I, for myself, my heirs, personal representatives or assigns, do hereby release, waive,
discharge, and covenant not to sue Slippery Rock University of Pennsylvania, and the State System of Higher
Education, part of the Commonwealth of Pennsylvania, and their officers, employees, volunteers and agents from liability
for any and all claims including the negligence of Slippery Rock University of Pennsylvania , its officers,
employees, volunteers and agents, resulting in personal injury, accidents or illnesses (including death), and property loss
arising from, but not limited to, participation in The Activity.
Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot be eliminated
regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from:
1) minor injuries such as scratches, bruises, and sprains; 2) major injuries such as eye injury or loss of sight, joint or back
injuries, heart attacks, and concussions; to 3) catastrophic injuries including paralysis and death.
[Representations: I certify that I am physically fit, have sufficiently prepared or trained for participation in The Activity,
and have not been advised to not participate by a qualified medical professional. I certify there are no health-related
reasons or problems which preclude my participation in The Activity.]
I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are
inherent in The Activity. I hereby assert that my participation is voluntary and that I knowingly assume all such
risks.
Release: I agree to allow my photo, video or film likeness to be used for any legitimate purpose by the event holders,
producers, sponsors, organizers and assigns of The Activity.
Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD Slippery Rock University and the State
System of Higher Education HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages
and liabilities, including attorney’s fees brought as a result of my involvement in The Activity and to reimburse them for
any such expenses incurred.
Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is
intended to be as broad and inclusive as is permitted by the law of the Commonwealth of Pennsylvania and that if any
portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement,
fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I
acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and
unconditional release of all liability to the greatest extent allowed by law.
_______________________________ ______
Signature of Parent/Guardian of Minor Date
Participant’s Age (if minor) ______
Land Use Project Request Form
______________________________
Signature of Participant
_____
Date
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Group name:
Please Print
]
Acknowledgement of Understanding: I acknowledge that I have read the attached Waiver of Liability,
Assumption of Risk, and Indemnity Agreement and fully understand its terms. I affirm that I am voluntarily
participating in the [
] (The Activity) and further acknowledge that I know, understand,
and appreciate the inherent risks of The Activity. I assume full responsibility for any and all injuries or damages
which may occur to me as a result of the inherent risks associated with The Activity.
Signature of Adult age 18+ OR
Print Name
Age
for MINOR Signature of Parent/Legal
Date
Guardian
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
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