The personal information that you provide on this form is being collected under the authority of the Post-Secondary Learning Act and the Freedom of Information and Protection of Privacy Act of Alberta. It will be used by the Confluence Campus to facilitate room reservations at the Confluence Campus. The information will be protected in compliance with the provisions of the Freedom of Information and Protection of Privacy Act of Alberta. The information will be retained by the department in accordance with approved Information Management guidelines, after which it will be destroyed in a secure manner. If you have any questions about the collection and use of this personal information, please contact the Learning Resources Manager, Information and Learning Resources, Red Deer College, 100 College Blvd., Box 5005, Red Deer, Alberta, T4N 5H5, Telephone: 403.342.3344

/ Request is hereby made by the undersigned for the use of the following school facilities of West Central High School or St. Dominic Catholic High School on the date or dates set forth below. Please note that all facility rental fees must be paid in advance. /

LESSEE INFORMATION

ORGANIZATION NAME / ADDRESS
REPRESENTATIVE NAME / TITLE / PHONE / FAX

RESERVATION INFORMATION

SCHOOL NAME / DATE
Facility required: / Gymnasium: / Room number(s): / No. of chairs to set up:
MONTH: / MONTH:
SU / M / TU / W / TH / F / SA / SU / M / TU / W / TH / F / SA
DATE / DATE
MONTH: / MONTH:
SU / M / TU / W / TH / F / SA / SU / M / TU / W / TH / F / SA
DATE / DATE
Additional requirements:
Facility opening time: / AM / PM / Closing time: / AM / PM
Event start time: / AM / PM / Ending time: / AM / PM
Will an admission charge, collection, donations, etc. be required? / YES / NO
The proceeds will be used for:

ACKNOWLEDGEMENT

The lessee hereby acknowledges that they shall be personally responsible, on behalf of the organization, for any damages sustained to the school premises, furniture or equipment because of the occupancy of the said premises by the organization. The lessee will also hold the Lessor from all and any liability for loss, costs or damages resulting from bodily injury, including death, of or to any person or persons. The Lessee agrees to abide by the rules, regulations and policies of the Wild Rose School Division, Red Deer Catholic Regional Division and Red Deer College governing the use of school premises.
SIGNATURE OF LESSEE / DATE
INTENTION/PURPOSE / REC. DEPT. APPROVAL
FOR OFFICE USE
PRINCIPAL(S) APPROVAL / CUSTODIAN APPROVAL W C H S ST. DOMINIC
Rental fee paid: / $ / Caretakers available: / YES / NO
Distribution: White – Application, Yellow – School Custodian, Pink – School, Gold – Confluence Campus Library / 10/08