District 319 Facilities Use Form Facilities Request Form Dates Requested Requestor's Name Group/Organization Phone: Email: Billing Address: City: State: ----- MN WI Other Zip: On-Site Supervisor in Charge On-Site Supervisor Phone Activity Information Name of Activity Area requested (check all needed) New Gym Stage Area Keewatin Gym Multi purpose room Small Gym Nashwauk Library Home Ec Room Other: Event Date(s): Event Start Time (indicate AM/PM): Event End Time (indicate AM/PM): Set-Up Time (indicate AM/PM): Tear-Down Time (indicate AM/PM): Estimated Number of Attendees: Will Admission be charged? Yes No Special Instructions/Requests *Nashwauk-Keewatin High School activities take precedence over non-school functions. *If the venue you've requested is not available, the Athletic Director may reserve a suitable alternative. *The Athletic Director District #319 Administration will have authority to deny or cancel any requests for facility use. Conditions for Use: Persons requesting facility use must be over 19 years of age. This application must be submitted 5 (five) working days prior to the date of use. Confirmation is not insured until you recieve a copy of this application back. A signed and dated copy of this application must be with person(s) using facilities. The facilities may be closed on days when school has been closed for emergency. When requested, submit a copy of an insurance certificate naming ISD 319 as a second insured, with a minimum $600,000 liability limit. Responsibilities of Adult On-Site Person in Charge: Supervision of all persons using the area requested. That persons using the area requested remain in that assigned area. That the area and equipment be used in a safe and reasonable manner. Counters and tables must be wiped clean (especially food, juice and markers). The room should be left in the same condition it was found. Turn off all electrical equipment, close all windows and lock doors before leaving. Report any injury to persons under your supervision to Sue Johnson, ISD 319 Facility Scheduler at 885-1280 ext.51171. Report all breakage or damage to building or equipment to Sue Johnson, ISD 319 Facility Scheduler at 885-1280 ext.51171. The adult person in charge will be responsible for any and all damage to building or equipment that is incurred as the result of inadequate supervision or improper use. The adult person in charge will be billed for the cost of repairs of replacement. The on-site adult person in charge must stay on site until all students are gone. I have read the above Conditions and Responsibilities and agree to follow all of them. Failure to do so and/or reports of misuse of any ISD 319 facilities will result in revocation of the contract and loss of any future privilege to utilize ISD 319 facilities. Send
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