Bangor Area School District

Facility Use Request Form

Any individual or group requesting to use any of Bangor Area School District’s facilities must use this form. This includes all Building and Grounds. This form must be submitted not less than two weeks before the need. Completion of this form does not guarantee that the request will be approved. Approval depends on availability of requested facilities, and needed district staffing and resources to accommodate the request. Every attempt will be made to issue a response to the request within five (5) working days of submission.

This section to be completed by the requestor.

Name of organization making request:

Individual representing organization:

Address:

Phone Number: E-Mail:

Facility requested. Please be specific. Check the school building and the specific facilities below:

High School Middle School DeFranco 5 Points Washington District Office

Auditorium Gym Lunchroom Kitchen Classrooms: Number

Lobby (When used alone) Dressing Rooms: Number Other (Specify )

Reason for request:

Type of Activity or Performance / Dates / Time Building Should Be Opened / Time Activity Starts / Time Activity Ends / Time Building Should Be Closed
1.
2.
3.
4.
5.
6.

Is Any School Equipment Required? Yes No If Yes, what equipment?

Overhead projector Screen Microphone Rostrum Kitchen equipment: Type

Stage lighting Piano Tables: Number Chairs: Number

DVD/TV Athletic equipment: Type Other:

Are the services of a school district operator required? Yes No

Type of program presented: Entertainment Play or Show Rehearsal Games

Recital Meeting Other

Will admission be charged: Yes No Price of admission:

For what purpose will the proceeds be used?

Approximately how many participants are expected (audience included)?

Approximately how many parking spaces will be required?

If this is a school event, please list the names of faculty members who have consented to be present and responsible during the entire time:

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Does the organization carry the required liability insurance? Yes No Policy Number:

Amount of coverage: Liability: Property Damage: Medical:

Name of Insurance Company: Name of Agent:

Address: Phone Number:

Signature of requestor: Date submitted:

This section to be completed by the building principal or Athletic Director.

Date received: Reviewed Disapproved

Signature: Date:

Comments:

This section to be completed by Scheduling Secretary.

Date Received: Scheduling conflicts No scheduling conflicts

Date submitted to Manager: Initials:

Comments:

Requestor Notified: Date: Mail Phone E-Mail

Principal A.D. Notified Date: Mail Phone E-Mail

Security Notified Date: Mail Phone E-Mail

Maintenance Notified Date: Mail Phone E-Mail

This section to be completed by Business Manager.

Date Received: Approved Disapproved

Comments:

Signature: Date:

Check if additional information is recorded by an agent of the Board of School Directors.

Where is the information located?

Deposit of Paid:

(Date)

Charges:

(Rental) (Custodian) (Other)

Total Charges:

RK 10/13