NAME OF ORGANIZATION:
NAME OF REPRESENTATIVE:
ADDRESS OF REPRESENTATIVE: TEL.
NO.
EMAIL ADDRESS
FACILITIES REQUESTED:
DATE(S) AND TIME(S) OF PROPOSED USE:
PURPOSE:
PLEASE EXPLAIN THE PROPOSED USE
AND NEEDS IN DETAIL
Fairview resident?
Membership Fee?
Has an insurance certificate been
submitted
from the
requesting organization that lists the Fairview School District as additional insured?
* Class IV groups are covered under the Fairview School
District Insurance (liability) coverage.
INSURANCE
CERTIFICATE MUST BE MAILED TO FAIRVIEW HIGH SCHOOL - ATTENTION - DALE
LEWIS. LIST FAIRVIEW SCHOOL DISTRICT AS ADDITIONAL INSURED, AND
NOT THE BUILDING WHICH YOU ARE REQUESTING.
ADDRESS:
FHS - 7460 McCray Road - Fairview, Pennsylvania 16415 Attention: Dale
Lewis
PROOF OF LIABILITY INSURANCE COVERAGE MUST BE PROVIDED.
(MINIMUM $500,000 LIABILITY COVERAGE PER OCCURRENCE UP TO 499 PEOPLE AND MINIMUM $1,000,000 PER OCCURRENCE FOR 500 OR MORE
PEOPLE. FAIRVIEW SCHOOL DISTRICT MUST BE LISTED ASADDITIONAL INSURED ON INSURANCE CERTIFICATE.)
THE ORGANIZATION AGREES TO INDEMNIFY AND HOLD THE FAIRVIEW
SCHOOL DISTRICT HARMLESS OF AND FROM ANY AND ALL LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE, OR LIABILITY
OF ANY OTHER KIND WHATSOEVER, IN CONNECTION WITH THE ORGANIZATION’S USE OF THE FACILITIES, AND AGREES THAT IT
SHALL AT ITS SOLE EXPENSE, DEFEND ANY LEGAL PROCEEDINGS BROUGHT AGAINST THE DISTRICT FOR PERSONAL INJURY OR PROPERTY
DAMAGE ARISING OUT OF THE USE OF THE FACILITIES IN ACCORDANCE WITH THIS APPLICATION, AND AGREES TO INDEMNIFY THE
DISTRICT OF AND FROM ANY JUDGEMENT ENTERED AGAINST IT. THE CAMPUS OF THE FAIRVIEW SCHOOL DISTRICT IS A TOBACCO AND
SMOKE-FREE ENVIRONMENT. POSSESSION OF WEAPONS ON THE CAMPUS IS PROHIBITED. THESE DISTRICT POLICIES WILL BE STRICTLY
ENFORCED.
PERSON(S) FROM
YOUR ORGANIZATION WHO WILL BE ON THE PREMISES AND IN CHARGE OF THE
ACTIVITY:
NAME:TELEPHONE: (H)
TELEPHONE: (W)
ADDRESS: CITY AND ZIPCODE:
FEE SCHEDULE
FACILITY AND
LOCATION
CLASS
I
CLASS
II
CLASS
III
CLASS IV
AUDITORIUM
Senior High School
$240.00
$120.00
N/C
N/C
Fairview Middle School
$120.00
$100.00
N/C
N/C
Fairview Elementary
$120.00
$ 80.00
N/C
N/C
GYMNASIUM
Senior High School
$120.00
$100.00
N/C
N/C
Fairview Middle School
$100.00
$ 80.00
N/C
N/C
Fairview Elementary
$ 60.00
$ 40.00
N/C
N/C
CLASSROOMS: (All Schools)
$30.00/hr.
$30.00/hr.
N/C
N/C
SWIMMING POOL
$50.00/hr.
$20.00/hr.
N/C
N/C
CLASS
I
CLASS
II
CLASS
III
CLASS IV
LARGE GROUP INSTRUCTION ROOMS
Includes choral room and any room seating over 49
persons
$30.00/hr.
$20.00/hr.
N/C
N/C
LABORATORIES
Not available to public except by special arrangements
$30.00/hr, plus lab breakage deposit of $100.00
N/C to colleges and other schools.
PORTABLE PROJECTOR & SCREEN AND ANY
OTHER SCHOOL AUDIOVISUAL EQUIPMENT
$5.00/event
CLASS
I
CLASS
II
CLASS
III
CLASS IV
FIELDS
Senior High School Stadium with dressing room $500.00
$300.00
$150.00
N/C
Senior High School Stadium with dressing room 7 $15.00 extra
with lights N/C outdoor lighting
Middle School field with dressing rooms
$120.00
$ 60.00
N/C No
dressing rooms.
WRESTLING ROOM
High School
$30.00
$ 15.00
$10.00 for special cleaning charge
N/C
EXPLANATION OF THE FOUR CLASSES:
Class I Non-resident and/or profit-making groups are Class I.
These activities must be of benefit to the community; e.g. Erie Area Soccer and Hamot Hospital .
Class II Resident groups which are non-profit but for which
admission is charged are considered Class II; e.g. Lion's Club.
Class III A resident group which has no membership fee,
admission fee, or other charges is Class III; e.g., Tri-Boro Baseball, Girl's Softball, Soccer League,
Fairview Recreation Authority.
Class IV A Board approved Booster/Parent Group e.g. Music
Boosters, etc.
Is the requesting organization a Class I, Class II, Class
III, or Class IV organization?
Is the planned date on a day when custodial and/or
maintenance staff are working regularly scheduled hours?
(Monday - Friday)
If no, requesting organization will need to reimburse the
district the cost of any custodial and/or maintenance help at a premium rate (1.5 times normal
pay rate)
plus pension and taxes. Note the rental fees in AP 707 that may
also be applicable.
List any special needs
QUESTIONS – FHS FACILITIES REQUEST
-
How many people will attend?
-
How many Fairview students
will participate?
-
Which parking lot(s) will be needed?
-
Have you done this before at Fairview ?
-
Where else have you held the event?
-
What costs did you have the last time you held the event
either here or elsewhere?
-
Is security necessary?
-
Do you charge admission?
How much?
-
Is this a fundraising event?
NOTE:
-
Who receives the funds?
-
Number of adult supervisors:
-
Will you need clock operators?
-
Equipment needs (such as mats, tables, chairs, microphones,
etc.): BE AS SPECIFIC AND THOROUGH AS POSSIBLE
PLEASE NOTE: The district would prefer that the person or
group making this request be present at the committee meeting during which the request will be discussed
to respond to questions by the Board committee. You will be notified as to the date and time of that meeting.
CHECK
OVER YOUR ANSWERS ABOVE TO SEE THAT THEY ARE CORRECT AND COMPLETE -- AND THEN
CLICK ON THE SUBMIT BUTTON BELOW.
Form put on Web 8/12/06 by David Park