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17-018.00 Central Valley School District: Open House, Appelway Trail Sullivan to Corbin Permit for Use of Ciaram.V.itu.EY School Facilities & Playfields *!STRICT MS Organization or Team City of Spokane Valley Date 1/24/17 . School Greenacres Mid41e School Person in Charge Rob Lochmiller Field, Diamond or Facility Cafeteria . Address 11707 E. Sprague Ave. , Ste 103 Starting Date 2/15/17 Time 5:00pm - Ending Dato 2/15/17 Time 8:OOpui • City Spokane Valley State_ WA Zip 99206 Week(s)of Event Phone 509-720-5010 Day(s)of Week Wednesday Email rlochmiller@spokanevalley.org Doors Open A.M. 5.30 P.M. Activity Ciassification Fee Insurance from Board Policy#4260 from Administrative Procedure#4260AP Use Fee per Hour 8.00 0 Yes Certificate of Insurance Q Gass I Box No. (124) $ for all use Is with district.*1 Custodian:3 hrs X$ 3 2.0(hr r. 9 6.00 . ❑ Class H Box No. (25-46) Name LI Yes Organization's Certificate Food Seryhrs X$ hr-` of Insurance attached**2 0 Gass III Name U Yes individual/Parent Hold Admission Charge Other Staff hrs X$ . Ar- Harmless Agreement Expected Attendance - Name Signed.***3 Estimate User Cost: $ 120.00 • • • *1. YMCA/SoccerAssodationlAAU/County Parks/et cetera **2. Scouts,4-H,SCOPE, Percussionauts.Club sports,Grange,Church groups,et cetera ***3. Individuals who may not be Insured with an insurance company f Explanation and/or special conditions (Users provide their own sanitalyfacllities)Need tables/seating for 40 with one table available for placing sign-in sheet and handouts. . .<g}.nr��i:t'^.' ,s(t:7iar:xrv,N:tCSvi::4:'+,,:'i�G'.t:: ::�:{,::_'•K.e:>a :ti fix:.. :.•tx•v •¢.ti• 7.y.• t^ic .)r"f:Lfx�-.-tura,{;:..,.i ..}i, >�ti�c. -r.�it h. .}'i.ih.•i�'i'/...�. ��^:�%<��,i�, ..l::f�:e::::t4•'i' �r...nZ:i:.., vat +,iv. .-,..> .,:c,,..,:•,'::'7j;t}::f}:S.r -::r�:4`i.•' b»+,:,v .� i ,f, .:.l'•.•`%.^ ti::a:,;`i, .,t i::i, �. > .Ef..f, :,.4-. •,ti,� .i ¢ .�•�.+.• C: .ti:nom`' '�'L• »t,.v,...:{ '•t;� .:;A ,.l `�i.i [le 1`'i kk [i.:.,1 4 ?< .1`•.i'3}- i,. _Y,i.,..:;.2.'Ji;:>.,, of �y vf,•, rte':,. 'ti!^Ll"� ,''•'''}±..4.v:4,4 ::-t•:L+'!.+ ..j:}., .�:{:: ,�•�..'.�wi,. Ci: ,,Fs.:.Rrdti:c!g '--r4;i.,.,:>:...1..�.q: - _ ;.,:. y y ,„ ,--•:,..-.4.Y•-;r,iw'•'..s:., '8�.:,•.!1•,..ti:w:p':t•>•�'L:•••:: u.:!.',; 1:r�..�, ...i,.`; •.v-„s;:. �_i:a�:.r�.+.;:. :.,,.i� i�d�c�-l�a�tlfniless-A'..r�e t31i+ir. •.rr•,_.a, o-.`'?''•�;}.'�r1.`c.a:-:,.;,, _3..•, _ - - _`•s....a— -.y:� �\§•:.hr,• -.� -.i•r •:C ' :c�:><•;`V�a•':i= :vl•<::a,S.,h:'r.'rr 4:•.. 1=.'the iindeistgned'agrees'aintf ackntowlded••r s t iattheUse of he facilities o1�en rel Vell'ey>,School d irlc(Wo:. @ js itadori br'urairan .the irc l•dlstr' its employees end agents,its to condtlori_'of fhe•'iopert ;The”, rsigned agrees to take tuft re onelblllty'fo an and d3arir ki the property or ' •to'' �i§onsallowed' yPo t..',.: lsesddi cited Wen tie miseaa ( ads ®a of acid?'';• ({a�atnat'Cehtral SthootbfsidctNd byau nen ended- a a`"ou off_ X9 11!9Wi<.rtdjte_mr�less �iiit ✓ :: a fl►1;x r,: '0Di t' > ,f.. a tOf use altie'mikes'. ` .'toaiiittirs teat 0 r.-distrfctforahy-nd etjirdgenlsiata�_ : ;"mass;tncklatng atFarne ,m.ia,I i a sc'•V s c vt'x t•';::� `•i'`` {.:••:.:ra>ie '6.•:...:a •._..:.::_.a`+`n.::<.:.:.::•......:......:•:.,.,t.•...,,«;,.,>.i:e.:.a.-:, ,'x:•+•.•.t•�•.,;., .. 8 u '�.t17�a,'i7::;.'"i`:1.:�;:vti%::S Sit>��^f':�:;7. i .. '7; .,ansa,r•is�o ep+:,e:,n,foo "5t,.:,,,a. •t:'The aid®a nod tines andwarrahta digisiiik ties te. or ariiiiiboil or road se sbti4of f:;: . ' p�D sj� q p �"}}ar f aclifdes,and sknr�gf'�ca ' a food'©�ppave 1 ,i> . €'shall ea ly with epos dderi 'state�end foal and regule ohs`regardln tira•serving and repamtloht Of eu food or bev` _TThhe(u n til i;"`. I,:spe ca jt agrees b CSpokane CBairj. Health District In order to ensu%thatall'r trid reguratorte end re eii iita;ir+d:r )40.1,1405p!ad b eri ' a�i,�ilccabnefood ��hI, y �yy,e�d� tel/rnecf r,c::..- .^�•::.:, .ti ;:x� ::t ,, ,.:.,; .,,.i.. � _ y,.., C� 10.#1 , 40. o tie'oi narXi+:^ ..-'7:,:.^i,:ig 1:.w.i.='i:•tY•: - ..:Ti :.1T•_,l., w:'.[':i �: p i j.'*'j.:7, -:-'::':.i:i e; ... �(�. 'ty ..�rgi.s��.;.::�:•,y< .w:lra...a^i:M>a:>,... ;t.r ix.`«- `+w,'C,r..._�v. ...!u•,. ,.i���, ..;i���: :.,,.�'•:• ,:s..';t,•.t:;.'i%:��~ _ .1v env!' i •ti i.,\..L�';�,. �'S'wi^fiY r_=". nN VC:<:.'•.[+;tt "C�i ,l`51'.l�+�i�.i?:,',`:iSl..�v. \ y,'�f�i l� � f t' ..:i,. t{: ') ,, n��'t7.iti. j %lilt•, '? f,t.:.`'1:4 I._ra 'esttrat the ar~aoviA forinoton Is cbnecf andif budda isiOti tivi $e used:I'ccordkrg to ale"poll� acid;procedures!of the CentratUalle c Schc ol.Disti •„z: ;' '',''t'�:t•`' �.. o15 •.+_\+'S{L.�.• y��r�<. y��..�r..�(:a•+,+,^I Dnh•'i:.C:: �,�._J "S.. F}�: � ,.t:procedures lift+\:. •<i ..4.. tA:.J]v7• n�=:..-;. �..C�.t, ij:,..ti. I fuflher ee t'o teknburse the iehoa ills t if as desa`ibed y3.'i:,I. t ilY':CC 'a:y'-iI}.\�n:. :50i::Wr.},„''..n:<".r.�,:a•'A'•,y,,:4.. . i3:,. � .#t9ic 'viii 'il�er'ccfsts � hie filial tiifbng'�" ,l' :, � ,,, ��.<��.:,•v,<.t .;,,�,..:..: :•.\:'.< _ _ A.- Kiri-.'u.. wy:,: ,-.,.. i;i•''• �'ci�..k�?,.�' f_ i�.�cgtF4'�i:. <;.n;ti ,.-yi. ,.�.. -<C'a .•t7,a11t 4tiPr4 l. .tir:.,..:::.C�:l.,_. 2.5'.'l:.�t1'Y•.:�f:�”:At'�{45,'+-,'•.'•,t,z^?r•---:FG;•i9tt:73aa'vz?':1;: 'w-'..K�?uY�=.4?+n:�:•r.Kt...i.� /:r n/a • ,a private non-profit youthverifies aNathletes and their parent/guand ian have compiled with mandated policies for the management of concussions nd headinjuries group,s coaches, prescribedby its 82d,section 2. Attached is a of insurance under an accident and lability.. issued by an insurance company aulhorizedito do business kt Waahlnlon State �y�or damage with at least$1.000,t�0 due to i• lorry or dath to one person and al teed$203.000,000 tilde to bodily Injury or death to two or .persons. ' i:, '-:ys:'.v�^:tttiTo'er sit "f:w.ja A::.. r• =..Fazzlte xs+.e=�.;s�.'�,�:''k'' zw::eiticac s%:,: Dated this 2G day of 4'✓`"41-Y 20 e 7 :Mate:Aw es td sct�iool tomes not be ' tr l ate'"'"'' ntirof th this z... ta5p�and � y �rifed �,�` ,tt appffc ori are o appfoilid by the sctlaol `'lar Jdf`o'f ifiaii i a'..•<: City of Spokane Valley L47-- !�_,ot.ry c-....N. Name of IndlvkfUal/Organtrattonff am 4011::thiotr,'Ilty.41 to Sign Title WNW: DM*Seelassa oao* School t' • w:ortrawbfrapini 4260 F • Revised 102011