Casey-Westfield CUSD #C-4

1) Upload Insurance Form

Max 10 files | 200 MB limit

2) What facility are you requesting?

Roosevelt

Monroe

High School

3) After completing this form, you will need to pay for your rental at Casey Westfield High School, put a deposit to receive a key fob and bring any paperwork necessary as seen in form below. (optional)

4) This application must be approved before a non-school related group is allowed to use school facilities. (optional)

School organizations, school-sponsored programs, and organizations whose primary purpose is to provide financial assistance to the school are all considered, for the purpose of this application, to be school-related. Use of facilites by any group outside of Casey-Westfield CUSD C-4 will not be allowed.

5) Organization Name

6) Adult Supervisor from Organization (must be 21 years of age or older)

7) Program/Activity

8) Phone Number

9) Date & Time Using the Facilities (including decoration/clean up time or any early entrance) (can take up to two business days to process)

10) Insurance provider name and contact number

11) All non-school related groups must agree to use appropriate emergency procedures including calling 9-1-1 for medical emergencies and whenever and AED is used.

*Disagreeing will void rental agreement

I Agree

I Disagree*

12) Activity being proposed is not in a physical fitness facility

True

False

13) I certify that am authorized to at for the above named organization.

I understand that:(1) the granting of this request does not constitute recognition of my organization as a school-related group or activity, and (2) my organization may not represent itself or any of its activities as school-related. I agree to: (1) abide by the conditions stated in this application, and (2) adhere to all Board policies and administrative procedures applicable to this use of the school's facility. *Disagreeing will void rental agreement

I agree

I disagree*

14) By agreeing I will read and abide by the policies and procedures that will be given upon approval of this form.

*Disagreeing will void rental agreement

I agree

I disagree*

15) Todays Date

Casey-Westfield CUSD #C-4

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