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Mineral County School District
Use of School Facilities & Grounds
10/18/2019
Is this application for:
Individual or  Group Use  
Name of Individual or Group: *
If group, name of responsible person: *
Address: *

                                In the event of a deposit refund, check will be mailed to address listed above.

Home: *()- Ext.
Business: ()- Ext.
Cell: ()- Ext.
e-mail address:
Date of Request: *
(Must be submitted at least two weeks prior to the event date.)


Title of the Activity/Event: *
Area of Facility or Grounds to be Used: *
Other:
Location: *
Proposed Schedule of Event(s) Use
DAY:
DATE:
TIME:
ACTIVITY:
DAY:
DATE:
TIME:
ACTIVITY:
DAY:
DATE:
TIME:
ACTIVITY:
DAY:
DATE:
TIME:
ACTIVITY:
DAY:
DATE:
TIME:
ACTIVITY:

List, attach or describe in detail additional dates, times, activities or schedules to be conducted if you are requesting multiple uses. (Example: athletic practices and game dates/times, etc.)

Attach additional list/schedule(s): Click to Upload Files


(NOTE: ANY EVENT/ACTIVITY/PRESENTATION THAT IS TO BE CONDUCTED DURING THE REGULAR SCHOOL DAY THAT REQUIRES TRANSPORTATION, DISRUPTS ANY SCHOOL INSTRUCTIONAL DAY, AND IS PRESENTED WITH OR WITHOUT AN ADMISSION FEE MUST BE APPROVED BY THE ADMINISTRATOR (S) OF THE SCHOOL(S) THAT ARE INVOLVED ALONG WITH THE SUPERINTENDENT PRIOR TO SUBMITTING THIS FORM.)



Is there an Admission Fee?

*
Yes  No  

(If yes, describe the cost of admission and what the proceeds will be used for.)


_____________________________________________________________________________________________

NOTE:

Mineral County Policy 7510 prohibits private individuals or organizations from using county facilities/grounds for profit.

BAN ON SALE, USE OR ADVERTISING OF ALCOHOL AND TOBACCO PRODUCTS

In accordance with State Board Policy 4373, 2422.5 and Mineral County Board Policy 7510, Board property may not be used for the advertising of any tobacco or alcohol product.  This ban shall apply at all times to any building, property, or vehicle leased, owned, or operated by the Board. This ban remains in force on evenings, weekends, and other times that school is not in session.

NOTE: The above announcement must be read at any event/activity where a public address system is used or available. In addition, Mineral County Schools will post this ban in appropriate places in and on its facilities/grounds.



DEPOSIT SCHEDULE

NOTE: During the course of a school year a deposit will be required based upon the total number of times the facility/grounds is being requested to be used. The amount of the deposit must be maintained at its original level when withdrawals are required to cover any damages or other expenses.

One (1) Event:    $100.00         Two (2) to Four (4) Events:   $300.00          Five (5) or more Events:   $500.00

A satisfactory inspection of the facility/grounds after each event will result in a refund of 80% of the original deposit.

Deposit has already been submitted through another individual organization.  

If so, list name of organization:


ALL DEPOSITS/FEES ARE TO BE SUBMITTED BY CHECK AND MADE TO: MINERAL COUNTY BOARD OF EDUCATION. CHECKS CAN BE GIVEN TO THE BUILDING ADMINISTRATOR OR MAILED TO: MINERAL COUNTY SCHOOLS; ONE BAKER PLACE; KEYSER, WEST VIRGINIA, 26726, ATTN: FINANCE OFFICE



ADDITIONAL FEE SCHEDULE

(TO BE COMPLETED BY BUILDING ADMINISTRATOR)

Custodial (as per daily rate)

Conditionally waived by building administrator*  

Cook (as per daily rate)

Conditionally waived by building administrator*  

Supervisor $20.00 per hour

Conditionally waived by building administrator**  

*After the required conference with the building administrator these fees may be conditionally waived. A satisfactory inspection of the facility/grounds after each event will determine if additional fees/charges will need to be imposed.

**This fee may be required if the supervising board employee is not approved by the building administrator and an additional supervising board employee needs to be secured to provide adequate supervision.



VERIFICATION OF LIABILITY INSURANCE

West Virginia Code: 18-5-19d and 29-12-5a requires that any individual or organization using board of education property must provide proof of liability insurance in the amount of no less than one million dollars for each occurrence. Any individual or organization who fails to provide proof of liability insurance in the amount described in the above code shall assume by signature all liability for property or personal damages that may be caused by any act, or failure to act, of the Mineral County Board of Education, its officers, agents, or employees. Risk of all dangerous conditions in and about the school property shall be assumed by the individual/organization and all specific notice of the existence of such conditions shall be waived.

*
I verify that I have proof of liability insurance for each event in the amount described by WV Code: 18-5-19d and 29-12-5a and have submitted such proof to the Mineral County Board of Education.  
I do not have proof of liability insurance for each event in the amount described by WV Code: 18-5-19d and 29-12-5a and will assume all liability for property and personal damages that may be caused by any act, or failure to act, of the Mineral County Board of Education, its officers, agents or employees. In addition, I shall assume risks of all dangerous conditions in and about the school property and waive any and all specific notice to the existence of such conditions.  


BOARD EMPLOYEE(S) RESPONSIBLE FOR EVENT SUPERVISION

The Mineral County Schools employee who is named below agrees to assume any and all supervisory responsibilities of the event/activity which include opening the facility, monitoring restrooms and grounds, ensuring satisfactory spectator behavior, ensuring facility/grounds clean-up, securing the facility/grounds, and any other duties that the building administrator assigns to ensure that the facility/grounds will be maintained to their satisfaction.

Name:
Phone (Home): ()- Ext.
Phone (Cell): ()- Ext.
Name:
Phone (Home): ()- Ext.
Phone (Cell): ()- Ext.

NOTE: If the building administrator is not satisfied that the board employee can carry out the duties and responsibilities for any reason, the individual/organization sponsoring the event will be required to secure another board employee which may result in an additional fee.



INDIVIDUAL/ORGANIZATION OFFICER ELECTRONIC SIGNATURE

The individual named on this form who represents themselves or the organization named on this form acknowledges that they have read all of the conditions of this form and fully understand the rules and regulations pertaining to the use of school facilities/grounds of the Board of Education of Mineral County and shall be responsible to insure that all laws, rules and regulations pertaining to such use of facilities be complied with. 

I acknowledge that by clicking on the "Submit" button at the end of this form (scroll down), I am indicating my intent to sign the relevant document and that this shall constitute my signature.

STOP HERE . . . THE REMAINDER OF THIS FORM IS FOR ADMINISTRATIVE USE ONLY

Please scroll down to hit the SUBMIT button.



BUILDING ADMINISTRATOR APPROVAL

By approving this form the building administrator verifies that he/she has done the following: 

1.) Met with the individual/organization and explained the specific conditions that are required for using the part of the facility/grounds that are being applied for;

2.) Have met with and approved the board employee who is responsible for supervision of the event/activity.

3.) Facility key(s) or fob has been returned, if applicable.

Security Deposit:
SECURITY DEPOSIT MUST BE SENT DIRECTLY TO FINANCE DEPARTMENT AT COUNTY OFFICE.


SUPERINTENDENT APPROVAL

Approved  Denied  
Reason(s):


THIS PORTION OF THE FORM IS TO BE COMPLETED AFTER THE EVENT(S)

VERIFICATION FOR DEPOSIT REFUND

The facility/grounds have been inspected and have been found to be satisfactory. A refund in the amount of 80% of the original deposit is to be returned to the individual/organization.  
The facility/grounds have been inspected and have been found to be unsatisfactory. Funds from the original deposit will need to be taken to cover extra costs of maintaining the facility/grounds back to a satisfactory condition.  
Describe Unsatisfactory Condition(s) and Approximate Costs:
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