ISD #2895 Jackson County Central Schools

Facility Use Request

Name of Group or Event:___________________________________________________

Building Requested:__________________ Room Requested:______________________

Date(s) Requested:________________________________________________________

Contact Person:___________________________________________________________

Day Phone:________________Eve:________________  Fax #:____________________

Mailing Address:___________________________Town/Zip__________________________

Email Address*: ___________________________________________________________

       *The best and quickest way to get your response and estimated costs. 

Time building is to be open:___________  Activity begins at:_______ Ends:________

Supervisor in Charge:_______________________________Approx. Attendance:______

Admission: (check one)  Free_____   Donation_____  Admission_____ Comm. Ed. ______

Equipment needed: check all that apply

       _____ Chairs (#___ )             _____   Tables (#__)          _____   Podium

       _____ Portable Microphone  _____    Sound System       _____   Projector/Screen

       _____ Bleachers                     _____  Locker Room/s      _____  TV/VCR

       _________________________________________ Other Requests (must specify)

All requests must have a local sponsor and be approved by the Board of Education.  There must be adequate adult supervision and if one of the kitchens are used, there must be a cook.

Liability: The persons and/or organizations using school facilities by signing and accepting a permit agree to indemnify the Jackson County Central Schools for any damage to the school and its property by any participant and public involved and agree to assume all liability for injury or death of any participant and public involved.  Any damage to facilities or equipment shall be reported immediately to the custodian on duty by the group supervisor.

I hereby certify that I am an agent of the above named organization and am authorized to accept in their name, the responsibility for observance of the rules and regulations of Jackson County Central Schools

Signature________________________________________  Date:_______________

(Facility Manager will complete info below & return to renter)

Approved for Use=Yes_____    No _____   JCC Facility Manager:_________________  Date:___________

Estimated Cost:    1.Rental:_________                 2.Equipment:__________

                              3.Services: Janitors ____            Tech. Booth ___           Other ____ =_______

                                            ____ hrs @ ____ /hr ____ hrs @ ____ /hr    ____ hrs @ ____ /hr              

                              Total Cost:___________

Renter’s Signature:________________________________________   Date: __________