Questions on the need to use this form? Email at the SRU Sustainability Office!
LAND USE EVENT or PROJECT REQUEST FORMSLIPPERY ROCK UNIVERSITY
Requested by (Name) / Title of Requester
Department/Budget Unit/Sponsor (Name) / Fund # / Fund Center #
College/Division (Name) / Telephone Number
SECTION I - EVENTor PROJECT INITIATION REQUEST
EVENT or PROJECT TITLE: ______
DATE(S) of Event or Project: ______
- Purpose of Request (check all applicable categories)
Permanent Change in Use of Land Install Permanent Structures, Signage, Paths, Walks, Roadways, Lighting, TrashReceptacles, etc.
Remove, Replace, or add Trees/Vegetation
Temporary Use of Land Install Temporary Structures, Signage, etc.
Please provide the following information as appropriate:
1. Land/Lot/Property Name ______2. Map Coordinates of Land ______or Mark up attached campus map
3. Current Area (acres) ______
______
4. Proposed Area(acres) ______
5. Current Land Use ______
6. Proposed Land Use
6. Proposed Land Use ______
7. Proposed Land Use Project Cost $0 Source of Funds: ____________
8. Proposed Land Use Annual Maintenance Costs $0 Source of Funds: ____________
9. Will any vertebrate animals be used for educational or research purposes? ____
NOTE: If “Yes”, SRU’s IACUC (Institutional Animals Care and Use Committee) approval is required BEFORE a Land Use Request Form will be reviewed. Go to IACUC’s website
for further information and to obtain
the protocol form to be completed. IACUC review/approval process takes approximately 30 days.
10. Will any animals be involved for non-educational/research purpose? ____
Note: If “Yes”, please attach documentation verifying the animal provider is a licensed vendor
complying with all Animal Welfare Act and other federal requirements.
11. Will this land use require any legal agreements with outside entities? _____
If “Yes”, attach draft legal agreement including any public liability insurance requirements.
12. If the activity involves potential danger to students or the public, you must have all participants
sign the attached waiver of liability form; a group sign-in form is also attached for your use;
these forms also must be completed as part of the Land Use Request.
13. For events requiring traffic control barriers, the person organizing the event must contact the SRU Police (Kevin Sharkey, 724-738-6139), who will help plan the traffic control needs and coordinate with SRU Facilities staff providing sawhorses for temporary road closures.
- Description of Event or Project
The Department Head/Budget Unit Head/Student Organization Sponsor is responsible for providing a brief description of the event or project proposed. Show how the changes/additions will assist the organization to better serve the intended audience (e.g., students, faculty, staff, community). Include any needs assessment data supporting the request. Clearly state changes desired, including any changes to existing structures, signage, trees, plantings, waterways, etc. Include a copy of the Campus Grounds Map, with the proposed land use area outlined on it with this form, including a description of any potential impacts of the proposed land use (number of participants/spectators per event, number of events per year, types of vehicles in use, if any, etc.). Please review the attached Campus Grounds Map to avoid planning an event or project that could adversely affect environmentally sensitive areas on campus.______
SECTION I – PROJECT INITIATION REQUEST APPROVAL
NAME
/ SPONSOR E-MAIL ADDRESS______ / ______
Department/Budget Unit Head/Student Organization Sponsor(same as indicated in the table at the top of this form)
SECTION II - PROJECT EVALUATION/IMPLEMENTATION APPROVALS
When you have completed the form, please save it as a document to your hard drive or diskette, naming it appropriately. You may then e-mail the document as an attached file to . Please DO NOT embed the document into the body of your e-mail. Additional supporting documentation can also be attached to this e-mail if it is in electronic format. Your request will be reviewed and forwarded to the appropriate University organizations for their recommendation. If any of these materials (request form and/or supporting documents) are only available in hard copy, forward them to the Paul Scanlon of the Sustainability Office (currently at the Macoskey Center, 247 Harmony Road) by campus mail.
You will be notified by e-mail as to the disposition of your request. Please note that, if this land use request is approved and the project includes construction involving SRU maintenance crews or outside contractors, a separate Space/Project Request Form must be used to obtain review/approval of the construction specifics.
SECTION III – PROJECT EVALUATION and/or IMPLEMENTATION APPROVALS
The President may solicit recommendations from the following groups or others, as appropriate:
Facilities & Planning NAME E-MAIL ADDRESS PHONE
Scott Albert x 4342
Dallas Cott x 2538
SRU PoliceKevin 6139
Environmental Zoning Committee Dean 2484
President’s Commission
On Disability Issues Scott Albert x 4342
President’s Commission
On Sustainability Paul Scanlon x 4268
IACUC
Simon Beeching x 2479
EH&S
Paul Novak x 2465
APPROVED BY:
NAME E-MAIL ADDRESS PHONE
724.738.2000
PresidentPhilip Way
This document uses the Garamond font to save ink and paper; please print on both sides of paper if hard copies are needed!
CAMPUS GROUNDS MAP – ENVIRONMENTALLY SENSITIVE AREAS
Participant's name: [Name ]
Please Print
SLIPPERY ROCK UNIVERSITY OF PENNSYLVANIA
[Name of class or activity]
Waiver of Liability, Assumption of Risk, and Indemnity Agreement
Waiver: In consideration of being permitted to participate in any way in
[Description of Class or Activity including date(s)]
hereinafter called "The Activity", I, for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue Slippery Rock University of Pennsylvania, and the State System of Higher Education, part of the Commonwealth of Pennsylvania, and their officers, employees, volunteers and agents from liability for any and all claims including the negligence of Slippery Rock University of Pennsylvania , its officers, employees, volunteers and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, participation in The Activity.
Assumption of Risks: Participation in The Activity carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. The specific risks vary from one activity to another, but the risks range from: 1) minor injuries such as scratches, bruises, and sprains; 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussions; to 3) catastrophic injuries including paralysis and death.
[Representations: I certify that I am physically fit, have sufficiently prepared or trained for participation in The Activity, and have not been advised to not participate by a qualified medical professional. I certify there are no health-related reasons or problems which preclude my participation in The Activity.]
I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in The Activity. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.
Release: I agree to allow my photo, video or film likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers and assigns of The Activity.
Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD Slippery Rock University and the State System of Higher Education HARMLESS from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in The Activity and to reimburse them for any such expenses incurred.
Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the Commonwealth of Pennsylvania and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
______
Signature of Parent/Guardian of Minor Date Signature of Participant Date
Participant’s Age (if minor) ______
Group name: ]
Please Print
Acknowledgement of Understanding: I acknowledge that I have read the attached Waiver of Liability, Assumption of Risk, and Indemnity Agreement and fully understand its terms. I affirm that I am voluntarily participating in the [ ] (The Activity) and further acknowledge that I know, understand, and appreciate the inherent risks of The Activity. I assume full responsibility for any and all injuries or damages which may occur to me as a result of the inherent risks associated with The Activity.
Print Name / Age / Signature of Adult age 18+ ORfor MINOR Signature of Parent/Legal Guardian / Date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Land Use Project Request Form