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Harney County SD3 Facility Request
Request for Facility / Equipment
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* Indicates required question
Name of Group
*
Your answer
Date of Request
*
MM
/
DD
/
YYYY
Person Responsible
*
Your answer
Contact Telephone
*
Your answer
Contact Email Address
*
Please provide a valid email address. Once you have completed the form, further instructions will be sent to you via email.
Your answer
Bill to
*
Your answer
Amount of Fee
*
Facility Fees for Facility Use will
Your answer
Contact Address
*
Your answer
School Needed
*
Burns High School
Hines Middle School
Slater Grade School
District Office Building (Lincoln)
Required
Date(s) and Time(s) Required
*
i.e. start and finish date(s) / time(s)
Your answer
Activity
*
Your answer
No. of Participants Expected
*
Your answer
No. of Participants Allowed
*
Your answer
Classification
*
i.e. District, Educational / Recreational, Civic, Private
Your answer
Check Facility Needed
*
Gym
Cafeteria
Stage
Classroom
Library
Locker Room
Kitchen
Other:
Required
Write in the Number of Items Needed
*
i.e. Chairs, tables, showers, bleachers, computers, printers, projectors, water, outlets etc.
Your answer
The user assumes all responsibility for any vandalism or damage which may occur to the facility while under their supervision and use. It is required that contact be made by the user with the activities director, 24 hours before the activity to enable them to locate any equipment and have it available for use.
*
I agree
I disagree
Required
Will there be a custodian on duty?
User will pay custodial costs incurred by the District
Yes
No
If there is no custodian on duty, does the group need to hire one?
User will pay custodial costs incurred by the District
Yes
No
Name of Custodian
Your answer
On duty from
Time
:
AM
PM
on
MM
/
DD
/
YYYY
until
Time
:
AM
PM
on
MM
/
DD
/
YYYY
Signature of Maintenance Supervisor
Your answer
Date
MM
/
DD
/
YYYY
Rate of Custodian Pay Per Hour
Group agrees to pay custodian if needed
Your answer
There will be a charge for custodial fees when a custodian is not on duty and is required to be at the activity. If the facility is used for profit, the district will get 10% of the NET, and will require a copy of the balance sheet. Equipment will be loaned for a maximum of three days. If more time is needed, special permission must be obtained.
*
I agree
I disagree
Required
Signature of User
*
Your answer
MM
/
DD
/
YYYY
Signature of Activities Director
Harney County School District 3
Your answer
MM
/
DD
/
YYYY
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