Code No. 905.1E1
FACILITY REQUEST FORM
The undersigned applicant makes application for the use of the school building designated below. Please refer to the Facilities Rental Procedures and Board Policy 905 to determine proper use of the facility. The applicant must complete a Facility Use Agreement prior to the use of facilities.
Today’s Date: _____________ Name of Organization/Group: ________________________________
Type of Organization (check one): __Non-Profit __For-Profit __Government __Educational
Representative Contact Information:
Name: _________________________________________ Phone: ______________________________
Address: _______________________________________ E-mail: ______________________________
_______________________________________
Building Requested: __ Middle School __ High School
__ Bailey Park Elementary __ Davis Elementary __ Fairview Elementary
Please select the area(s) of the building you wish to rent:
__Auditorium __Main Gym __Secondary Gym __Cafeteria
__Band/Choir Room __Mini-Theatre __Media Center __Classroom
__Other _____________________
Purpose of Use: _______________________________________________________________________
Date(s) to be used: ___________________________ Time range of use (include am/pm): __________
Is it a fundraising activity? Yes No If yes, where do funds go? _____________________________
Estimated number of participants: Youth: _________ Adults: ___________ Seniors: ______________
Additional Equipment Requested: ________________________________________________________
Name of Insurance Company? _______________________________ Policy #: ____________________
_____________________________________________________________________________________
Signature of Applicant Date
Approved: 03-13-13
Reviewed: 07-11-18
Revised: 05-08-13
Grinnell-Newburg School District, Grinnell, IA