Facility Usage Request Form
Organization Making Request
*
Contact Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Code
Facilities Requested
*
Please Select
Adult Ed.
Arlington
ASE
Batchelor
Binford
BGS
BHSN
BHSS
Childs
Clear Creek
Office of Early Learning
Fairview
Grandview
Highland Park
HHCC
Jackson Creek
Lakeview
Marlin
Rogers
Service Bldg
Summit
Templeton
Tri-North
Transportation
Unionville
University
Supervisor E-mail
example@example.com
Admin Asst E-mail
example@example.com
C3
example@example.com
C4
example@example.com
Is a Pool Required for this Request?
*
Please Select
Yes
No
Date Desired
*
-
Month
-
Day
Year
Date
Time Desired
*
Hour Minutes
AM
PM
AM/PM Option
Alternate Dates/Times
Please Utilize This Field if Selecting Multiple Dates
Nature/Details of Event
*
Number of Anticipated Attendees
*
Other Considerations for this Request
Business Type
*
Please Select
Non-Profit
Other
Tobacco Free Policy
I agree to the Tobacco Free Policy
*
Yes
MCCSC Guidelines 7510 - Use of School Facilities
Fee Table
I agree to the fee tables and responsibilies as outlined in MCCSC Guidelines 7510 - Use of School Facilities shall this request be approved.
*
Yes
Name of Qualified Attendant for Pool Use
First Name
Last Name
I Agree to Comply with Provisions of Pool Use
Yes
Please Attach Your Most Updated Certificate of Insurance Below:
*
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This is for organizations outside of MCCSC
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