| General Information |
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| Name
of Individual or Group Requesting: |
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________________________________________ |
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| Date(s)
Building or Equipment is to be used: |
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______________________________________ |
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| Time(s)
Building or Equipment is to be used: |
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______________________________________ |
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| Name
of Individual Responsible: |
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_______________________________________________ |
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| Address: |
____________________________________ |
Telephone #: |
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_________________ |
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| Profit
or Non-profit Organization: |
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_______________________________________________ |
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| State
Purpose of Request for Use
(Please be specific) |
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| Buildings
and Rooms or Equipment Requested (Please be specific) |
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| School
Personnel Requested
(Please be specific) |
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| Conditions (To be completed by the Superintendent) |
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| Agreement: I, ____________________________
representing |
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_______________________ |
| hereby
make request for use of buildings and equipment listed above and agree to the
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| conditions
stated. |
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| Signature
of Person Requesting: ________________________________ |
Date: |
_______________ |
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| Approval
or Denial |
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| Staff
Signature_____________________ |
Request Granted or
Denied: ____________ |
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| Activities
Director___________________ |
Request Granted or
Denied: ____________ |
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| Superintendent's
Signature: ___________________________ |
Date:___________ |
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| Reason
for Denial if Denied: |
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