BLOOMINGTON INDEPENDENT SCHOOL DISTRICT

Request for Use of Facilities

DATE OF REQUEST:         __________________________

NAME OF SCHOOL/LOCATION REQUESTED: __________________________________________________________

Date Requested: _____________________                                                              Time:     From ___________ to _________

Purpose for which premises will be used: __________________________________________________________________

____________________________________________________________________________________________________

Will an admission fee be charged?                  Yes ___________               Fee Amount ___________              No __________

It is understood that Bloomington ISD accepts no liability for damage or negligence on the part of an individual or organization while facilities are in use.

We agree that all debts incurred by this agreement shall be paid to the Bloomington ISD within ten (10) days of the event. If any of the rules and regulations of the Board governing the approval of this application are broken, this application is automatically cancelled.

We have read the rules and regulations of the Board (Policy GKD Local) which we agree to observe if permission is granted, and further agree to exercise the utmost care in the use of the premises and property and to make good any damages or loss of property arising from our occupancy of any portion of the building. We understand that if the facility is damaged or is left unclean we forfeit our deposit.

FEES: (For any usage of facilities that is not for a district event.) Fee may be waived at the discretion of the Superintendent.

Deposit in Case of Damages: $100 (Will be returned if no damages occur and facility is left clean.)

Use of Employee to Unlock and Re-lock Building or Gate: $20

Energy Usage Fees:                                                                             Security Fee:  

                Building Room Usage- $20/hr                                          (If the district feels it is necessary for security to be present at your

                Placedo Gym- $15/hr                                                         event, you will also be charged the cost of this service. If you are

                High School Gym- $25/hr                                                  providing security, it must meet district approval.)

                Field with Lights- $50/hr                                                    

                Field without Lights- $25/hr                                 _____________Total Hours

$_____________Total Fee

$_____________Total Paid       _____________(Received payment)

                                                                                                                                ____________________________________

                                                                                                                                Requesting Organization/Contact Person

                                                                                                                                ____________________________________

                                                                                                                                Requester’s Signature

                                                                                                                                ____________________________________

                                                                                                                                Address

                                                                                                                                ____________________________________

                                                                                                                                                                                                                                                                                                                                                                              ____________________________________

                                                                                                                                Email address

____________________________________

                                                                                                                                Phone #

____________________________________________________________________________________________________

____________________________________

Calendar Checked

Approved: Yes _____   No _____                 

___________________________________                                              ____________________________________

Building Principal                                                                             Superintendent of Schools