SHENENDEHOWA CENTRAL SCHOOL DISTRICT

Clifton Park, NY 12065

Revocable License for Facilities Use

                                                                                                                        Event # ___________

TO BE COMPLETED BY THE APPLICANT:

Organization Name _______________________________ Contact Person: _____________________

Phone Numbers: Home ____________________Work ________________ Fax __________________

Billing Address ________________________________________ Email _______________________

Description of Event _________________________________________________________________

Number of Participants ______ # of Shenendehowa Residents ______ Admission Fee? ______         

Building Requested: ________________

Classroom(s) _____________Gym _______   Cafeteria ______________Kitchen Facilities ________

Auditorium _____________    Field(s) ___________  Stage _____     Other ______________________

Specific Dates Requested:         Start Date _________              End Date _____________

Day                                         Dates                                      Beginning Time          Ending Time

Sunday _____________________________              _____________          ____________

Monday           _____________________________              _____________          ____________

Tuesday           _____________________________              _____________          ____________

Wednesday      _____________________________              _____________          ____________

Thursday          _____________________________              _____________          ____________

Friday              _____________________________              _____________          ____________

Saturday           _____________________________              _____________          ____________

Canceled Dates _____________________________________________________________________

Other Needs:

A/V Equipment                     Yes ____ No___                                  Cooking/Equipment             Yes _____             No _____

Specific Table/Chair Set Up               Yes ____ No___                  Diagram                                Yes _____             No _____

Security Personnel                               Yes ____ No___                  Other ________________________________

Explanation of Needs: _____________________________________________________________________________

_______________________________________________________________________________________________

# of parking spaced needed _____                  Insurance on file: Yes _____             No _____              Attached ___

Diagram of set up attached?                              Yes _____             No _______

Agreement: The applicant(s) agree to be bound by all rules, regulations, and requirements, including those related to insurance and indemnification, contained in the Use of Facilities Handbook (receipt of which is hereby acknowledged.)  The applicant also agrees to assume all financial responsibility for all and any damage done to school property during the above indicated period of use.  The applicant also understands that all school programs are given first priority in use of facilities and as a result, an applicant activity could be canceled and/or rescheduled because of a school activity/program.

Signature of Applicant ___________________________________________________               Date ____________

TO BE COMPLETED BY THE DISTRICT:

Group Classification _______                           Security Deposit _________

Hourly Room Rental rate $________                           Custodial Cost (if applicable) $ __________

Special Event Fee $ _____________

______ Yes, Request can be approved as submitted    

______ Request can be approved with the following changes:

Administrator’s Signature ___________________________________________       Date ________

An approved copy of the School license form is proof that reservations and arrangements have been made with the appropriate school officials for use of facilities.