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
Arlington Heights
Binford
Childs
Clear Creek
Fairview
Grandview
Highland Park
Lakeview
Marlin
Rogers
Service Building
Summit
Templeton
Unionville
University
Batchelor
Jackson Creek
Tri-North
Academy
BGS
Bloomington North
Bloomington South
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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