File: KF-E

MSAD #41 BUILDING USE AND RENTAL APPLICATION

Name of applicant
Address of applicant
Building requested			Telephone #:
Building section requested			Date(s) requested
Hours requested			Type of Activity
Admission charged?	Yes	No	Anticipated # of Attendees

NEEDED BELOW: Signatures, addresses, and telephone numbers of two or three sponsors who agree to be responsible for any violation caused by non-compliance with the rules and regulations of the MSAD #41 Board of Directors.

NAMES

ADDRESSES

PHONE #

If the application is granted, the applicant is responsible for the payment of any rental and associated use charges, for the preservation of order and liability for any damage to the building and equipment or loss of property that may result, and for due observance of regulations of the Board. The applicant accepts full responsibility for any injuries that may occur to individuals associated with the activity or function for which the building is being used/rented.

APPLICANT PLEASE NOTE:

_ Kitchen use fee to be billed after requested date of building use, if checked off below.

_ Custodial fee to be billed after requesting date of building use, if checked off below.

_ A Certificate of Insurance naming MSAD #41 as “Additional Named Insured” may be required.

Applicant’s signature:

Date:

M.S.A.D. #41 USE ONLY:
Application approved for			hours on
Date
Certificate of insurance required?					Yes		No	Date received
Kitchen use fee charged?		Yes			No
Custodian to be hired		Yes			No	Explanation:
Other fees:	Yes	No		Explanation:
Signed:									Building Principal
Signed:									Superintendent of Schools

Form SO-1 (3/02)

First Reading: April 3, 2002

Adopted: May 1, 2002