Application and Permit for Use of Facilities

APPLICATION AND PERMIT FOR USE OF FACILITIES – 2017/2018 Val Verde Unified School District, 975 W. Morgan Street, Perris, CA 92571, (951) 940-6100 Application must be received by the Facilities Dept. 10 working days prior to Scheduled Event or it may be denied.

1. FACILITY REQUESTED (School Name, Site or Facility Type) 2. Today’s Date:

3. Description of Activity: Is FOOD being served? YES NO If YES, exactly what is being served, who is providing the food, who is serving it?

4. APPLICANT: (Group or Individual) 5. Outside Organization You Are Affiliated With:

6. Address (street, city, state, zip): 7. Telephone Number and Email (required):

() email:

8.a. Building, Room, Grounds, Special Facilities Requested ( FOR APPLICANT TO COMPLETE):

8.b. Building, Room, Grounds, Special Facilities Assigned ( FOR SITE TO COMPLETE): MPR/Gym Stadium Field#______Field#______Rm#_____ Rm#_____

Other:

9. Equipment and/or Set-up Requested ( FOR APPLICANT TO COMPLETE): # of tables:_ _ # of chairs: _ Sound System Mics Other:

10. Charges. If charges are to be incurred, the terms are: (a) 50% of fee payable with submission of application. (b) Balance seven days prior to use. (c) Payments made payable to Val Verde Unified School District. Failure to comply with the terms will be cause to deny permission. FOR VVUSD SCHOOL & DISTRICT EVENTS scheduled outside normal school day hours (7:30am to 4:30pm) or on weekends, Sections #11, #12, & #13 MUST BE COMPLETED.

12. Funding for Custodial/Maintenance/Security Overtime Support: 11. Is Custodial / Maintenance/Security Support Required:

YES NO **If NO, COMPLETE #13 below Account Code:

13. **If NO for #11, please complete: (a) Please explain who will open/close facility/site, (b) what site staff will be attendance and in charge of event for the duration of the event? :

______

Dates Requested: Hours of Use: Person in Charge of Event: Vehicles to be On Premises: Estimate Attendance:

Lic #: From: To:

I. DECLARATION OF APPLICANT

1. Nature or type of intended use: ______

1. Applicant has received or will receive for the activities herein listed contributions, cash collections, registration fees, admission fees, tuition, donations, or other receipts estimated in the amount of $______. If no receipts anticipated for these activities check here .

1. Receipts set forth in item 2. above will be used for:

1. I, the undersigned, hereby certify that I will be personally responsible on behalf of the applicant for any damages sustained by the school building, furniture, equipment, or grounds occurring through the occupancy or use of said building and or grounds by the applicant, normal wear and tear excepted.

1. I hereby certify that I have received and read the rules, regulations, conditions and terms including those on the reverse side of this application and that I and the applicant which I represent, will abide by them and will conform to all applicable provisions of the Constitution and laws of California and to all other rules and regulations of the Board of Education and its authorized agents which may be communicated to the applicant.

1. It is agreed that in the event this permit is canceled by the applicant no refund will be made and that changes in date or extension of time shall be made only as specified by the rules governing use of school facilities. 7. In executing this declaration I certify that I have been duly authorized by the herein set forth applicant to act in its behalf in making application for use of said facilities. HOLD HARMLESS & INDEMNIFICATION AGREEMENT THE UNDERSIGNED AGREES TO DEFEND, INDEMNIFY AND HOLD HARMLESS THE VAL VERDE UNIFIED SCHOOL DISTRICT, ITS BOARD OF TRUSTEES, AGENTS AND EMPLOYEES, INDIVIDUALLY AND COLLECTIVELY, FROM AND AGAINST ALL COSTS, LOSSES, CLAIMS, ACTIONS, AND JUDGMENTS ARISING FROM PERSONAL INJURIES, PROPERTY DAMAGE OR OTHERWISE, HOWEVER CAUSED, THAT MAY ARISE FROM OR BE ALLEGED TO BE CAUSED BY THE UNDERSIGNED’S USE OR OCCUPANCY OF DISTRICT FACILITIES, FURNITURE OR EQUIPMENT. THE UNDERSIGNED FURTHER AGREES TO PROVIDE A CERTIFICATE OF INSURANCE FOR LIABILITY COVERAGES SATISFACTORY TO THE DISTRICT, IF APPLICABLE.

Applicant understands submission of application does not constitute automatic approval. Applicant understands that a copy of application stamped APPROVED must be available at all times when using a Val Verde Unified School District facility.

Signature of Applicant: Date:

II. SITE APPROVAL

SITE MANAGER APPROVES Application: (verify above info)

SITE MANAGER DISAPPROVES Application: Please explain:

SITE MANAGER SIGNATURE: Date:

Custodial Services Required: Yes No Name of Custodian:

III. DISTRICT OFFICE (D.O.) APPROVAL D.O. MANAGER APPROVES Application: INSURANCE REQUIRED INSURANCE NOT REQUIRED

D.O. MANAGER DISAPPROVES Application: Please explain:

D.O. MANAGER SIGNATURE: Date:    FOR OFFICE USE ONLY   

1. Insurance Required: Yes No $1,000,000 Property/Liability with A Rating) 4. Other Services: Yes No

Describe: 2. Security for Event Required: Yes No (Required for 50+ Attendees)

3. Office authorization for Custodial Services: Yes No

Comments/Exceptions:

Schedule #: (Board Approved;June 2, 2015 ) APPLICATION EXPIRES JUNE 30, 2018 page 1