19-047.01 Central Valley School District 365: Facility Use Permitc�'
CE NTRAL VALLEY
SCHOOL DISTRICT .355
Permit for Use of
School Facilities & layfields
Organization or Team C A
Person in Charge -
(_., I s_ . C! ..
Address
Ciiy� f \irl! \,r^tib.\(r.jState `, ZipC'C /D(
Phone �`�Lt I— t�
Email
Date 5 / 1 jf i cl9
School IC l'\L'--' t--
Field, Diamond or Facility
Starting Date (0) OS) H
Ending Date _ CO I O J I `1
Week(s) of Event
Day(s) of Week
Doors Open
A.M.
Time (o C' G
Time
P M.
Activity Classification
from Board Policy #4260
D Class I Box No. (1-24)
Fee
from Administrative Procedure #4260AP
Use Fee per Hour $
insurance
D Yes Certificate of Insurance
for all use is with district. *1
� ,.Yes Organization's Certificate
of Insurance attached. r`2
D Yes Individual/Parent Hold
Harmless Agreement
Signed. ***3
Custodian' hrs X $ hr =
D Class II Box No. (25-48)
_
Name
D Class III
Admission Charge
Food Servs hrs X $ hr=
Name
Other Staff hrs X $ hr=
Expected Attendance
_
Name
Estimate User Cost: $
*1. YMCA/SoccerAssociation/ARU/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
Explanation and/or special conditions (Users provide their own sanitary facilities) \--*"'; \(:1; !
S •Nr6 \eC
Hold Harmless Agreement
The undersigned agrees and acknowledges that the use of the facilities of Central Valley School District No. 356 is without representation or warranties by the school district,
Its employees and agents, as to the condition of the property. The undersigned agrees to take full responsibility for any and all damage to the property and/or injury to
persons allowed or reasonably anticipated to be on the premises by the undersigned. The undersigned specifically waives any and all rights, remedies, or causes of action
against Central Valley School District No. 356, its employees and agents, from any and all claims arising out of the use of the premises and agrees to reimburse the school
district for any and all judgements, costs and expenses, including attorney's fees, incurred by the school district in the defense of any such action.
The undersigned further agrees and warrants that should the respective organization or group use school district facilities, and serve or prepare any food or beverage, it
shall comply with all applicable federal, state and local laws and regulations regarding the serving and preparation of such food or beverage. The undersigned organization
specifically agrees to contact the Spokane County Health District in order to ensure that all required regulations and requirements are met, including, but not limited to, any
applicable food permit that is required to be obtained.
I agree that the above information is correct and the building facilities will be used according to the policies and procedures of the Central Valley School District
I further agree to reimburse the school district for actual user costs as described in the final billing.
, a private non-profit youth sports group, verifies all coaches, athletes and their parent/guardian have
complied with mandated policies for the management of concussions and head injuries as prescribed by HB 1824, section 2.
Attached is a proof of insurance under an accident and liability policy issued by an insurance company authorized to do business in Washington State
covering any injury or damage with at least $1,000,000 due to bodily injury or death to one person and at least $2,000,000 due to bodily injury or death
to two or more persons.
Dated this day of Ma_/�/� 20
(
Ok_ C — .\\(), (1. 1,—
Name of individual/Organization/Team
White: District Business Office
Yellow: Organization/Team
Pink: Principal
Note: Access to school facilities may not be granted until all requirements of this
application are complete and approved by the school district andlor designee.
17/
Person Authori •e. to Sign Title
School Principal
4260 F
Revised 3/2011