23-079.00 Central Valley School District: Sullivan Rd Preservation Facility Use Permit for Use of CENTRAL VALLEY
School Facilities & Playfields SCHOOL DISTRICT
APPLICANT:ORGANIZATION/GROUP/TEAM INFO FACILITY&USE INFO
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Organization/team name: C141 4A -3pcj (av a `VaaUe School/location: • z\av(VS E12y i1kar\t
Person in charge: -1-(,_TViV1 01/1VV1.kq Field or facility: C'a }>pvj 3_
Address: I D t O E.. JV1 )P 7�)E±- Event or type of use:r t�,��nt.t C 4J�Ese r c
City/state/zip: &.r � ' t cf1 Un_ Dates: c4 I 19 `�3 3
Phone: (�JC. i ) 'o— Gj� Times: Gj- 1 tinn
Email: Cif v►...k�e...ir1.(„y1f►\. .a,.`[ •Or5 Details:.t C YV eeh' it) at S C L)..$S
Number of atendees:_ ! J U4X'cmt n5 C[Y13�VkK 2.% \ 1
Admission charge If applicable: NL rat Attach schedule,program,explanations or special c nditions,etc.
Activity/User Type
4550001 or child-related groups or other government agencies(e.g.,Scouts,PTA,4-H,city or county recreation groups,Peace Corps)
Nonprofit groups(may use facilities for lectures,promotional activities,rallies,entertainment,college courses or other activities)
Commercial enterprises(includes profit-making organizations and business-related enterprises)
_
—Private non-profit youth sports group:Must verify all coaches,athletes and their parent/guardian have complied with mandated
policies for the management of concussions and head injuries as prescribed by HB 1824,Section 2.
Estimated Fees:See Administrative Procedure 4260:www.boarddocs.com/wa/cvsd/Board.nsf/Public
Food Service: Hours: x Rate: =Subtotal$ Name: Use Fee: Hours: Subtotal$
QCustodian: Hours: x Rate: =Subtotal$ Name: Other: Hours: Subtotal$
Other Staff: Hours: x Rate: =Subtotal$ Name: Estimated Total: $
Other: Explanation or special conditions:
Sanitary Facilities:Applicants/Requesters must provide their own sanitary facilities(e.g.,porta potty).
Insurance: Proof of insurance does not need to be submitted with permit,but is required before approval and use of facility/playfield.
Certificate of insurance for all use is with district(e.g.,YMCA,soccer assn.,AAU,County Parks)
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rganization's certificate of insurance attached(e.g.,Scouts,SCOPE,club sports,church groups)
Individual/parent hold harmless agreement signed(e.g.,individuals not insured with an Insurance company)
The District does not maintain insurance that will respond to claims against the applicant arising out of the use of the facilities by the Applicant,Its members,or those
attending the event.The applying Group/Organization is required to be covered by comprehensive general liability insurance.The applicant is responsible for obtaining said
insurance and,at the time this application Is presented,must also present satisfactory proof that such a policy Is or will be Issued to cover the proposed use If this request Is
approved.The application will not be approved until satisfactory evidence of insurance naming Central Valley School District as additional Insured is presented.Such
Insurance shall be Issued with an Insurance carrieY licensed to do business In the State of Washington and carries an A.M.Best rating of not less than A-.Policy shall
maintain at least a$1,000,000 per occurrence limit with an annual aggregate of not less than$2,000,000.
Hold Harmless Agreement
The undersigned agrees and acknowledges that the use of the facilities of Central ValleySchool District No.356(CVSD)is without representation or
warranties by the school district,its employees and agents,as to the condition of the property.The undersigned agrees to hold harmless,indemnify and
defend for any and all claims,costs,damages including but not limited to 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 CVSD,
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 CVSD.
I further agree to reimburse the school district for actual user costs as described in the final billing.
i attest by my signature that I and all persons associated with the organization/group/team will abide by all COVID protocols in effect including but not
limited to masking and s ' I stancing in accordance with the DOH,SRHD,OSPI,WIAA or CDC rules and protocols appropriate for our group.
Authorized f412�+ 6 7 " 3 7$(23
Signature: Title: 1 Date:
Principal
L -�U Signature:
FACILITIES I REV.OCT 2021