Facility Use Application

1.	Building/Facility Requested*

2.	Application Date
	mm/dd/yyyy

3.	Requested By*

4.	Organization*

5.	Phone*

6.	Street Address

7.	City/State/Zipcode

8.	Email Address

9.	Activity or Event*

10.	Area(s), Room(s), Facility or Space Requested*
	Request

11.	Is Access to Kitchen Required? If YES - additional costs for food service worker will apply. If NO - access to any kitchen space will be prohibited.
	Is Access to Kitchen Required? If YES - additional costs for food service worker will apply. If NO - access to any kitchen space will be prohibited. YesNo

12.	Sponsor/Person in Charge* Required to be on site.

13.	Phone*

14.	Cell Phone

15.	Estimated Number Attending  (99,999,999)

16.	Date(s)/Time(s) Requested*
	Date(s)   Day of Week   Time(s) - AM/PM   Fees/Charges to Participants/Spectators Request 1         Request 2         Request 3         Request 4         Request 5         Request 6         Request 7         Request 8         Request 9

17.	Needs
	Lectern  Chairs  Piano  Parking  AV Equipment   Stage Lighting  P.A. System  Restrooms

18.	If you need Chairs - How many?

19.	Will you need to move any heavy objects in or out of the school?
	Will you need to move any heavy objects in or out of the school? YesNo

20.	Will you need to park any buses or large vehicles on school district property?
	Will you need to park any buses or large vehicles on school district property? YesNo

21.	If Yes, how long?

22.	Will special equipment be used? (Tap shoes, rollers, casters, etc.)

23.	Are you planning to pitch tents?
	Are you planning to pitch tents? YesNo

24.	Is your organization planning any Small Games of Chance?*
	Is your organization planning any Small Games of Chance?* YesNo

25.	Will you require specific security needs?
	Will you require specific security needs? YesNo

26.	If Yes, what will they be?

	Please complete all questions of application and submit to the Pottsville Area School District within thirty (30) days of the first event. Applications will not be processed without all completed documentation including the certificate of insurance.