CAMPBELL UNION
SCHOOL DISTRICT
155 North Third
Street, Campbell, CA 95008 (408) 364-4200
REQUEST
FOR PERMIT TO USE SCHOOL FACILITIES
(download
Non-District-Sponsored Use form as PDF)
First priority for use of school facilities will be
given to organizations, which directly serve the students and/or residents
of Campbell Union School District.
Name of Applicant_______________________________________________________________________
Telephone Number____Day________________________Evening________________________________
Mailing Address________________________________________________________________________
School_______________________________________Type of
Activity____________________________
Request Use of: Multi-Use_____,
Library_____, Other_________________________________________
Date(s)________________________________________________________________________________
(Please list each date requested. Use a separate sheet if necessary.)
______________________________________________________________________________________
Hours Needed_________________________________
Special Equipment, Personnel needed, other conditions__________________________________________
_________________________________________________Estimated
Attendance___________________
Participation Charged: Yes_____No_____ Net Proceeds used for________________________________
After completion of this request, submit it for signature
to the Site Administrator for review. The
form will then be forwarded to the Facilities Coordinator for final determination on the facility use.
CONDITIONS AND FEES FOR USE
OF SCHOOL FACILITIES/FIELDS
The Permittee agrees to comply with regulations of the
School District:
1. To
observe all laws, signs and regulations applicable to the premises which
includes:
A. Smoking
and the use of tobacco products are prohibited anywhere on District property.
B. Alcoholic
beverages are prohibited anywhere on District property.
C. Vehicles
are permitted in designated parking spaces only.
D. An
adult supervisor is required to be present at all times during all activities
on school property.
E. Skateboarding,
roller blading, and bicycle riding are prohibited on school grounds.
F. No
animals, including dogs, are allowed on school property unless necessary
for the reasonable accommodation of disabled persons. (Documentation
required.)
G. Use
of school facilities by any group shall not interfere with school activities.
2. To
pay for all damages or loss of property, which occurs during the PermitteeŐs
use of school facilities.
3. That
the Permit is issued for the dates and hours stated above and is revocable
at the will of the District.
4. That
the activity shall be under the direct supervision of the undersigned
Permittee who accepts all responsibilities.
5. To
provide a certificate of Insurance of at least $1,000,000 for bodily
injury and $1,000,000 for property damage, with the Campbell Union School
District named as additional insured. The underlying insurance shall cover the acts or omissions
of the Permittee, in occupying the premises.
6. That
any violation may lead to the revoking of this permit.
7. To
secure the facility at the end of activity and
á Clean
up all areas used by group. Dispose
of refuse.
á Place
all tables, chairs and equipment in the location it was prior to use.
á Lock
and secure all windows and doors, turn off lights.
á Notify
custodian or security personal of your departure.
8. That
no metal cleated footwear is allowed on the fields.
9. That
fees in connection with the permit of facilities use will include:
á Charges
for the use of utilities such as water, gas, and electricity. (If applicable.)
á The
costs of custodial supplies such as toilet paper, soap and paper towels.
á If
the premise is used during the hours when a custodian is off-duty, there
will be a charge for his/her services.
á If
use of the kitchen is requested, a Food Service employee shall be assigned
and there too, will be a charge for these services.
10. To
certify that the group, association, league, organization, person or
persons listed below shall not practice discrimination against persons
because of race, color, religious creed, national origin, ancestry or
sex.
INDEMNITY AGREEMENT
Facility User agrees to defend,
indemnify and save harmless the Campbell Union School District, its
officers, members of the governing board, agents and employees, each
severally and separately, from and against any and all liabilities,
demands, claims, damages, losses and expenses of any nature whatsoever,
including without limitation, attorneyŐs fees and other legal costs,
whether for injuries to persons or loss of life or damage to or theft
of property occurring on, in or about the Facility, arising out of
the Facility UserŐs use of the Campbell Union School District Facility.
I have read, understand and agree
to the conditions required by Campbell Union School District, and the
fees included with this request.
Signature: Applicant_______________________________________________Date_________________
Federal Tax ID Number_____________________________________________Date_________________
Reviewed with Site Administrator_____________________________________Date_________________
(Site Administrator will ensure the availability
of the room, assign a room number if necessary and schedule the date(s)/times
on site calendar prior to signing and forwarding application.)
Signature: Food
Service Administrator_________________________________Date_________________
Approved by Facilities Director ____________________________________Date_________________
FEES
Processing Fee_____________________ Room
Rental________________________
Field Deposit______________________ Field
Use Fee_______________________
Custodial Fee______________________ Food
Assistant Fee___________________
Other Miscellaneous Fee(s)____________________________
Enrichment Program _________________________________
AdministratorŐs
Signature (Extension Program)
Program paid through indirects _________________________
1/1/06 AdministratorŐs Signature (Extension Program) |
