Western Dubuque County Community School District
Use of Facilities Request Form - Epworth Elementary
5/23/2019

To review WD Board Policy information on Use of Facilities and Equipment, click on the links below:

905.1 Community Use of School District Facilities & Equipment
905.1R1 Rules/Regulations for Facility Use
905.1E1 Facility Rental Schedule
905.1E2 Comm. Use of Dist. Facilities & Equipment Indemnity & Liability Ins. Agreement
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Sponsoring Organization
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Is this a Student or Adult Group?
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Is this Group Inside or Outside Western Dubuque School District boundaries?
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Please select all that apply to your group/team/organization:
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Non-Profit Organization  
Booster Club/PTO benefiting Western Dubuque Schools  
For-Profit Organization/Business  
Participation is open to all students in the community  
Participation is selective and/or tryouts are held  
Coach is a non-paid volunteeer/parent  
Coach receives compensation  
Participation/membership is free  
Participation is not free (enter the annual cost below)  

If participation/membership is not free, enter the annual cost here:
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Please select all that apply to the ACTIVITY for which you are requesting facility usage:
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Facility to be used for rehearsal/practice  
Facility to be used for competition/game/tournament/performance/class  
Admission will be charged  
Any profit will go directly to Western Dubuque Schools  
Any profit will be used to support Western Dubuque Schools (Booster/PTO)  
Any profit will NOT go to Western Dubuque Schools  
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Yes  No  
Has a Certificate of Liability or copy of your homeowner's insurance policy been provided to Building Principal? (Required for rate class III or IV.)
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Name of your Property/Liability Insurance Company

Policy Number
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Event Title
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Event Details: Please provide a detailed description of what the event will entail
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NOTICE:  If shool is released early or cancelled, due to inclement weather, outside teams and groups will not be allowed to use school facilities at that time."

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Start Date and Time of Event
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Recurring Event
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End Date and Time

Event Frequency

If recurring monthly event, specify which week of the month event will occur.

If recurring monthly event, specify which day of the week the event will occur.
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Equipment Needed (i.e. tables, chairs, projector and screen, athletic equipment, show choir risers, choral risers, sound shell and clouds, etc.)
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It is hereby acknowledged that I have read the guidelines for use of school facilities and understand their content. I am authorized to sign this agreement on behalf of the organization named above. The Board of Education shall be held harmless for any damages to persons or property arising from the sponsored activity. The failure to abide by the above-mentioned terms or repeated wanton abuse of the facilities will result in cancellation of this and any future contracts. I agree to notify the building principal in the event of a cancellation or variation.
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Signed: Representative of Sponsoring Group (Contact Person)
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Date (mm/dd/yyyy)
*()- Ext.
Phone Number

Contact Email
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Address (Include Street, PO Box)
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City
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State
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Zip Code
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Auditorium Use Questions:
What time will the auditorium need to be open to the public or user group?:

Lighting Needs: Please check which best describes what you need for event

Sound Needs: How many microphones will you need?
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 Use of Kitchen:

Will you need use of the kitchen?: *
Yes  No  
Will you need use of the Gym?:
Yes  No  
Cafeteria?:
Yes  No  
Library?:
Yes  No  
If using gym for basketball, indicate the height you want basketball rims set at:
7 feet  8 feet  9 feet  10 feet  

BUILDING PRINCIPAL MUST COMPLETE ALL SECTIONS BELOW REGARDING FACILITY USE CHARGES PRIOR TO APPROVING (REFER TO BOARD POLICY LINKS ABOVE)

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Rental Schedule Class

Facility Use Charges ($)

Other Charges ($)

Amount of Deposit ($)

Custodian Charges ($)

Hours

Other Personnel Charges ($)

Hours

Is facility use billable or non-billable?

Special Notes

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Routing Instructions
Please route this form to the following personnel:
1. Building Secretary
Complete the information below to route your form. * Indicates Required Fields
Your Name:
* Your E-mail: *
Confirm E-mail: *
Send to Approver:  
No approver has been assigned to this form, please contact your District Forms Manager.