905.1E1- Use of School Facilities Application Form
905.1E1- Use of School Facilities Application FormThe undersigned entity makes an application for the use of the school district facility or equipment as designated below. The entity will provide police protection at its own expense, if necessary, to maintain order and to properly protect the building, site, or equipment.
Please refer to school board policy to determine the proper use of school facilities and equipment. The entity is responsible for complying with the law, board policy and the administrative regulations.
The entity must provide proof of insurance prior to the use of school district buildings, sites, or equipment.
To be completed by individual making request:
DATE OF REQUEST:
Person Making Request: Phone No. :
Person/Group Using Equipment/Facilities:
Reason for Request:
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Facility Requested:
The person / group affirms that all adults using facilities have been checked on Iowa’s Sex Offender Registry (SOR).
This is to confirm that no one entering the building or working with children is on the SOR.
(Printed Name and Signature required)
If using classrooms, please list classrooms requested or attach a map.
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Concession Stand:
____ Will operate our own concession
____ Will have a school organization operate the concessions.
Name of group:
Additional Equipment Requested: (Projection system, bleachers pulled out, podium, etc.):
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Specific Date(s) Requested:
Specific Time(s) Facilities are Needed:
Actual Time of the Event:
Responsible Adult:
Address: Phone No.:
TO BE COMPLETED BY BUSINESS OFFICE:
Date Received:
Superintendent’s Approval:
Board Approval If Necessary:
Custodial/Cook Required: Yes No
___________ Custodian(s) How Many __________________ Hours Needed ______________
___________ Food Service How Many _________________ Hours Needed _____________
_______________ $50 Minimum Fee Required When Using Kitchen Area
Custodial/Cook Arrangements Completed: Yes No
Note Arrangements:
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Arrangements of Keys:
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Charge: (Note Items and Cost):
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Charge Paid to Dunkerton Schools: Yes No
Custodial Hours - Start Time: End Time: Total Hours:
Food Service Hours – Start Time: ________ End Time: ________ Total Hours: ________
Total Fee$ ___________
Upon completion of the event, the area was checked and no damages were found. Area is in the same condition as the group used.
Site Supervisor Signature:
Building and Grounds Supervisor:
(Submit to the business office when completed).
Approved: 6/28/17
Reviewed: 9/27/17, 1/6/22
Revised: 12/20/17, 4/25/18