FLUVANNA COUNTY PUBLIC SCHOOLS Application for Use of School Facilities

File KG-R1

Applicant Information Name of Organization: Authorized Agent:

Phone:

Fax:

Contact Person:

Phone:

Fax:

State:

ZIP Code:

Beginning Time:

Ending Time:

Current address: City:

School/Site Information School/Site: Space(s) to be used: Date(s) to be used: Total Hours: Number of Participants Approximately:

Other Event/Activity Information Specify the purpose for use of space: Equipment or Food-Service needs (specify): Is Organization non-profit? Insurance Requirement: each applicant is required to carry a minimum of $1,000,000 in liability insurance coverage for all School Facilities activities. A certificate of Insurance will be required naming the Fluvanna County Board as an additional insured to this policy prior to final approval of any application. Please attach a copy of your Certificate of Insurance.

Applicant Agreement 1) We will be responsible for payment of the rental fee upon approval by Building-level Principal. Fees will be calculated based on the chart on page 2. 2) This permit may be canceled by the Superintendent or designee at their discretion 3) That we become responsible for any and all damage to the site, building, and/or equipment, for the duration or the time(s) and date(s) listed on the application and understand that we will not be permitted to use the school property again if we fai l to That undertake these 4) we agree tomeasures indemnify and hold harmless the School Board, and all of its officers, employees, and agents from any and all claims demand, suits causes of action, or judgments any person had, now has or may have in the future against the event which the subject this liable agreement 5) The is School Board of is not for anything we do or sponsor while using these facilities Monthly payment or rent: 6)This organization has an open membership policy and does not discriminate on the basis of race or sex 7) We understand that smoking and alcohol use are prohibited on school property 8) We will restrict usage to assigned areas and observe contracted time limits 9) We will obtain prior approval before any signs, placards, or banners are erected on school property 10) We agree to follow all requirements set forth in Regulation KG-R

Signature Authorized Agent Signature:

E-mail:

Date:

Signature of co-applicant:

E-mail:

Date:

The following designations classify various organizations and groups for the purposes of establishing priority for use and for the charging of fees

Eligible Organizations Type I Organizations

School and School Division sponsored organizations for activities related to School Division programs or business; Associated organizations, such as PTOs/PTAs and Booster Clubs, for activities supporting School Division programs; Youth organizations, such as Boy Scouts, Girl Scouts, YMCA, and 4-H Clubs for programs, meetings and activities that do not require a direct fee for participation in such activities; Fluvanna County Local Government agencies and departments for programs and activities serving Fluvanna County citizens; Virginia High School League for District and Regional athletic events; and

Type II Organizations

Fluvanna County organizations focused on youth activities

Type III Organizations

Other fee-based programs and other activities by organizations not covered by Types I and II, Fluvanna County community and civic associations.

COMMUNITY USE OF SCHOOL FACILITIES FEE SCHEDULE

Quantity Needed/hr

Site Manager/Custodian

$24.00/hr

Food Services Staff

$24.00/hr

AV/Lighting Technician

$24.00/hr

High School Auditorium (requires Lighting Tech)

$40.00/hr

Central Elementary & School Board Auditorium

$30.00/hr

Library

$25.00/hr

Classroom

$15.00/hr

High School and Middle School gymnasium

$40.00/hr

Elementary and Auxiliary gymnasium

$25.00/hr

Cafeteria Synthetic Turf Field Competition Grass Athletic Field Practice Field

For Office Use Only Calculation

$25.00/hr $50.00/hr youth $100/hr other $35.00/hr $10.00/hr

Additional Fees Description: Subtotal of fees Late payment fee (if any) Total Fees Due Cancellation of a rental must be done at least three (3) business days before the rental. Cancellation later than three (3) business days will result in the renting organization being assessed three (3) hours rental fee and three (3) hours personnel fees. Office Use Only 2nd Personnel Need: Fax: Employee name:

1st Personnel Need: Employee name: Application is Recommended for

□

Approval

□ Denial

Applicant Notified of Recommendation by:

by

Principal Signature

Date:

Application is:

□

Approved

□

Denied

Superintendent/Designee:

Date:

The Fluvanna County School Board does not discriminate on the basis of race, color, ethnicity, religion, age, national origin, marital status, disability, sex, status of a parent, or any other legally protected status in the provision of employment services, programs, activities or treatment. The Assistant Superintendent is designated as the responsible person (Compliance Officer) regarding assurances of nondiscrimination. Any complaint alleging discrimination based on a disability shall be directed to the Director for Special Services (the Section 504 Coordinator). Both may be reached at the following address: 14455 James Madison Highway, Palmyra, VA 22963; telephone (434) 589-8208. The Fluvanna County School Board is an Equal Opportunity Employer.