Facility Use Request - Middle School

Title

First Name
*

Last Name
*

Address
*

City
*

State
*

Zipcode/Postcode
*

Phone Number
*

Email Address
*

Organization
*

Group/Organization Category *

(*Proof of Liability Insurance Required)

Grade/Age of School Age Participants
*

Intended Use of Facilities (i.e. meeting, practice, etc)
*

Facilitie(s) Requested *

KHS
KMS (PLEASE Indicate New/Old Building in
"Other" Column under Room Desired)

KES
Outdoors

Room(s) Desired *

Gym
Stage
Cafeteria

Media Center
Band Room
Conf. Cntr./Conf. Rm.

Classroom
Other
Class Room # (or "Other")

Date(s) Desired *

Time Activity Starts/Ends (for release to public on event calendar) *

**Times Reserving Facilities (inclusive of set-up/tear-down) *
(**NOTE: Change of hours or cancellations must be made 24 hours prior to event).

Remarks and Equipment Desired

PLEASE NOTE: FACILITY USE REQUESTS MUST BE SUBMITTED FIVE (5) WORKING DAYS PRIOR TO THE EVENT. THIS FACILITY USE REQUEST IS NOT VALID UNTIL APPROVED BY THE BUILDING PRINCIPAL AND PERMISSION GRANTED BY THE SUPERINTENDENT. WHEN PERMISSION IS GRANTED, APPLICANT WILL RECEIVE A COPY AND, AT THAT TIME, WILL HAVE PERMISSION TO USE KEYSTONE FACILITIES.

BEVERAGE CONTRACT NOTICE: Keystone has an exclusive beverage contract with Pepsi Americas. Any individual, group or organization selling carbonated beverages, bottled water or sports drinks on property owned or leased by Keystone Local Schools must purchase those items from Pepsi Americas. For purchasing information contact Pepsi toll free at 800-874-0693, ext. 209.

FACILITY USE FEE (effective July 1, 2005)
· $25 per hour during custodial/maintenance/cleaning staff regular scheduled work hours.
· $75 per hour outside custodial/maintenance/cleaning staff regular scheduled work hours.
· Charges to be billed according to rooms/areas used.

Invoice For Facility Use Fee (if applicable)

Adult Supervisor(s)/Advisor(s) to be present at time(s) facilities are being used (name/contact info.) *

DECLARATION: My signature affirms that I have read and understand Board Regulations, Community Use of School Facilities (KG-R), and that the information provided on this facility use request is accurate to the best of my knowledge.

Applicant Signature

Enter Word Verification in box below *