Revised 1-1-06
The section below to be completed by person requesting use of school facility:
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2. Circle the facilities requested: gym cafeteria athletic field kitchen library parking
lot classroom (how many?)
______ other (please specify)
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Activity: |
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Date (s) of Activity: |
(Please
be specific.) |
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Hours of Activity: |
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3. Group Making Request: |
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Person’s Name Making Request: |
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Address: |
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Your Telephone: (home) |
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(work) |
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Are you affiliated with the county or city recreation department? |
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4. Please Read: |
· No school facility may be used for a private, for-profit business. |
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· There will be no smoking, alcohol or drug use by individuals while on school grounds. |
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· Possession of knives, guns or any weapon on school grounds will lead to arrest and prosecution. |
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· School facilities may not be used on dates or at times not specified in this agreement. |
By signing this form, I agree to abide by all the rules & regulations of the Iredell-Statesville Schools Board of Education and understand that my group is responsible for all damages to school facilities, property and equipment which occur during the time we are using the facility.
In addition, I acknowledge that my group assumes full and complete responsibility for any and all injuries or accidents to persons or property which may occur during our use of the facility and that school insurance does not apply.
And, I agree that we are responsible for the safe & orderly conduct of all persons on school grounds and may lose the privilege of using school facilities if any of these rules or agreements are broken.
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5. Signature of Person
Requesting Facility |
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(date) |
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This section below to be completed by School Principal or Designee:
1. Check the Category This Group’s Request Falls Into:
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Category I |
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Category II |
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Category III |
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School-sponsored group or organization |
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Community Service Clubs & Organizations |
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All requests from groups not included in Categories I or II |
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Adult education program or function sponsored by Mitchell Community College |
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Government-sponsored Recreational programs |
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Other Government Groups (Volunteer Fire Departments, Rescue Squads, etc.) |
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2. Determine the Costs for Services Requested or Required:
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Category I: No Charge |
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$0.00 |
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Category II &
III: |
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Utilities: |
Classroom |
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hours
@ $10 per hour = $ |
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Elementary
Gym |
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hours
@ $15 per hour = $ |
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Middle
School Gym |
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hours
@ $20 per hour = $ |
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High
School Gym |
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hours
@ $20 per hour = $ |
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Outside
Lights |
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hours
@ $20 per hour = $ |
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Auditorium |
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hours
@ $20 per hour = $ |
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Sound
System |
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hours
@ $10 per hour = $ |
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Security |
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hours
@ $11 per hour = $ |
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Cafeteria
(dining area) |
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hours
@ $15 per hour = $ |
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Kitchen* |
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hours
@ $40 per hour = $ |
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(*Cafeteria
worker must Supervise) |
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hours
@ $20 per hour = $ |
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Other
Fees: |
Supervision |
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hours
@ $20 per hour = $ |
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Clean
Up |
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hours
@ $20 per hour = $ |
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Field
Rentals: |
For
Category III groups |
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hours
@ $5 per hour = $ |
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(Add
$100 field use fee if extended rental (i.e. league play)) |
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3. Calculate Total Charges
Due: |
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$ |
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4. Authorizing Signatures: |
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Principal
or Designee
(date) |
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Central
Office Administrator
(date) |
MUST BE
COMPLETED IN TRIPLICATE