Organization name

Requested school facility

Adult Supervisor from Organization (must be 21 years of age or older)

Phone/email address

Program/Activity

Date(s) and start/end time(s)

Equipment needed 

Materials to be brought into facility

Room arrangement, including decorations

Food service required

1.  All non-school related groups must supply adequate supervision to ensure proper care and use of school facilities.

• The non-school related group is responsible to the Board for the use and care of the school facility. All adult supervisors must have cell phones with them at all times.

• Sufficient, competent adult supervision must be provided and the adult supervisor must ensure that no minor is left alone after the activity.

• Only the cafeteria, auditorium, gymnasium, and athletic field, along with needed hallways and parking areas, are available for community use. Entering any room or area not in use by the group is prohibited. The adult supervisor will vacate the facility at the scheduled end time. Use of the school facility is not permitted past the agreed end time.

• No furniture or equipment may be moved without prior approval from the Building Principal.

• Signs, displays, or materials may not be attached, nailed, or otherwise affixed to walls.

        Initial here if this is agreeable

2.  All non-school related groups must agree to:

• Indemnify and hold harmless the District and its agents and employees for and from any and all loss including attorneys’ fees, damages, expense, and liability arising out of its use of school property. 

• Pay any damages to school facilities, furniture, or equipment arising out of its use of school property whether such damage was accidental or deliberate.  The cost of damages will be based on the repair or replacement cost, the choice of which is at the School Board’s discretion.

• Supply proof of insurance naming [insert name of the District] as an additional insured and verifying that the group maintains adequate insurance coverage against personal injury and/or property loss:                                     

                Insurance provider name and contact number

        Initial here if this is agreeable

3.  All non-school related groups must pay the following fees:

Rental charge (unless waived by Board policy):            

Meal and beverage service (cost as determined by the cafeteria supervisor):                

        Initial here if this is agreeable

4.  Payment Method:    ☐ Check    ☐ Money Order    ☐Credit Card

    If payment is by check, please make check payable to:              The District            

    If payment by credit card, please indicate the following: ☐Visa  ☐Master Card   ☐Am Ex

    Expiration date:        Credit Card No.                      Today’s date        Authorized amount:              Authorized signature:                    

5.  All non-school related groups must agree to use appropriate emergency procedures including calling 9-1-1 for medical emergencies and whenever an AED is used.

        Initial here if this is agreeable

6.  All non-school related groups must agree to follow the District’s Plan for Responding to a Medical Emergency at a Physical Fitness Facility, 4:170-AP6. Important: The District will not supervise the activity nor will it supply trained AED users to act as emergency responders at any time, including during staffed business hours.

    ☐ Activity being proposed is not in a physical fitness facility. 

        Initial here if this is agreeable

    ☐ Copy of the District’s Plan for Responding to a Medical Emergency at a Physical Fitness Facility has been provided. (77 Ill.Admin.Code §§527.400(a) and 527.800(c). Important: State law encourages all non-District coaches, instructors, judges, referees, or other similarly situated non-District anticipated rescuers who use the physical fitness facility in conjunction with the supervision of physical fitness activities to complete a course of instruction that would qualify them as a trained AED user under Ill. law (410 ILCS 4/10; 77 Ill.Admin.Code §527.100).

        Initial here that a copy of the Plan was received and that the Applicant has read and understands the above note.

7.  If the request involves a physical fitness facility, the non-school related group must:

• Designate at least one adult supervisor who agrees to be an emergency responder. All emergency responders are encouraged to be trained in CPR and trained AED users.

• Give a copy of the District’s plan for responding to medical emergencies to each designated emergency responder.

• Require that 9-1-1 be called for medical emergencies and whenever an AED is used.

• Ensure that each designated emergency responder knows the location of first aid equipment and any AED.

• Ensure that only trained AED users operate an AED, unless the circumstances do not allow time for a trained AED user to arrive.

• Arrange for at least one emergency responder to have a tour of the facility before the activity. 

• Ensure that if an AED is used, the Superintendent is informed and all appropriate forms are completed.

        Initial here if this is agreeable

Applicant name (please print)

Telephone number

Address 

Email address

Applicant signature 

Date

Superintendent or designee

Date