Fillable Application District Facilities Use

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Application District Facilities Use

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Cerritos College
Application and Agreement for Use of District Facilities
ORGANIZATION
Name: Type of Organization:
Address: City: State: Zip Code:
Name of Event:
AUTHORIZED REPRESENTATIVE/APPLICANT
Name/Title:
Business phone number: Ext Cell phone Number:
Fax Number: Email Address:
DESCRIPTION OF ACTIVITY
❑ Cerritos College School Activity (Details on how it is directly related to students is required):
❑ Non-School Activity:
❑ Activity open to the public ❑ Entrance fee charged
❑ Concert ❑ Dance/Theatre ❑ Dining ❑ Filming ❑ Lecture/Speaker
❑ Meeting ❑ Performance ❑ Photo Shoot ❑ Sports Event ❑ Training/Workshop
❑ Web Shoot ❑ Other
Date of Event Expected Attendance Access Time Event Start Time Vacate Time
❑ AM ❑ PM ❑ AM ❑ PM ❑ AM ❑ PM
❑ AM ❑ PM ❑ AM ❑ PM ❑ AM ❑ PM
❑ AM ❑ PM ❑ AM ❑ PM ❑ AM ❑ PM
❑ AM ❑ PM ❑ AM ❑ PM ❑ AM ❑ PM
11110 Alondra Blvd.
Norwalk, CA 90650
marshall@cerritos.edu
562.860.2451, Ext. 2303
Civic Center
Dennis Marshall
Facilities Scheduling Coordinator
LOCATION/VENUE
Request is hereby made for use of the following facility:
❑ Aquatic Center ❑ Conference Room ❑ Soccer Field
❑ Baseball/Softball Field ❑ Gymnasium ❑ Tennis Courts
❑ Common Area ❑ Locker Room ❑ Teleconference Room
❑ Classroom/Lecture Room ❑ Stadium (Football/Track & Field) ❑ Outdoor Amphitheatre
❑ Special Request/Other ❑ Utility Field
HOLD HARMLESS AGREEMENT
Responsible party entering into agreement: I have read and understand the rules, regulations and policies of the Cerritos
Community College District and assume responsibility for adherence. Organization/Applicant shall be responsible for any damage
sustained on District premises, furniture, or equipment due to the occupancy of said premises. Organization/Applicant agrees
to hold the Cerritos Community College District, its governing board the individual members thereof, and all district officers,
agents, volunteers, and employees free and harmless from any loss, liability, cost or expense that may arise during, or be caused
in any way by, such use of occupancy of District premises.
CERTIFICATE OF INSURANCE/ENDORSEMENT/WORKERS COMPENSATION
$1,000,000.00 minimum liability insurance required. The certificate must identify Cerritos Community College District as
additional insured and be accompanied by an endorsement. District may require increased minimum liability amounts if event
or activity warrants additional coverage. Cancellations require 72-hour notification period. All expenses incurred by the Cerritos
Community College District prior to cancelation are non-refundable.
Organization/Applicant shall maintain workers compensation insurance as required by the State of California and Employer’s
Liability Insurance.
SIGNATURE
❑ I have reviewed, understand, and agree to abide by the Civic Center and District Facility use Agreement
Applicant Name/Please Print
Signature/Date
Organization/Title
Address City
State Zip code
❑ Approved ❑ Denied
David Moore
Signature/Date
Director of Physical Plant/Construction Services
Cerritos College
11110 Alondra Blvd.
Norwalk, CA
OFFICE USE ONLY
Date
Invoice Number #
Estimated Cost $
Invoice Amt. $
Deposit Amt./Due $
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Application District Facilities Use

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Completed 9 June 2020

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