LAKE CHELAN SCHOOL DISTRICT

PO BOX 369

CHELAN, WA 98816

509-682-3515 FAX 509-682-5842

The Lake Chelan School District firmly believes that our facilities belong to the community. Safety & security are top concerns for all of us. These procedures have been developed to ensure safety, security, proper usage, maintenance & cleanliness of areas used.

BUILDING USE APPLICATION

NAME:__________________________________________ DATE:______________________

ADDRESS: ______________________________CITY:_____________ZIP:__________________

GROUP NAME:______________________________________________PHONE:______________

PURPOSE OF RENTAL/USE:___________________________________________________________

BUILDING/ROOMS NEEDED: DATE: TIME:

____________________________ ____________ ________TO __________

____________________________ ____________ ________ TO __________

____________________________ ____________ ________TO ___________

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

EQUIPMENT REQUESTED:

TABLES____________ CHAIRS _________ PROJECTOR ___________ SCREEN _________

AV EQUIP ______________ OTHER (EXPLAIN)_________________________________________

RENTAL CHARGES:

RENTAL FEE_____________CUSTODIAL _____________ TECH ___________ COOK __________

KEYS WILL NOT BE GIVEN OR LOANED TO ANY USER

Opening and closing of facility will be done by school staff.

HOLD HARMLESS AGREEMENT / CONCUSSION TRAINING CERTIFICATION

The Renter/User hereby agrees to indemnify and hold harmless the Lake Chelan School District, its appointed and elected officials and employees while acting within the scope of their duties as such, from and against all claims, demands, loss, liability of any kind and character, including costs of defense, arising out of or in any way connected with the renter/user’s use of the school facilities specified in this agreement.

As a non-profit youth sports group, the signature below verifies all coaches, athletes and their parent/guardian have complied with mandated training and 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 $50,000 due to bodily injury or death or one person and at least $100,000 due to bodily injury or death to two or more persons.

Signature of Applicant ______________________________________ Date _______________________

User Group is insured by :_______________________________________________________________

COPIES TO : ______________________ _____________________ _____________________

_____________________ _______________________ _____________________