Are any of the following high-risk activities planned for your event?
1. Circus performances, animal shows, or similar traveling shows?
□
Yes
□
No
2. Carnivals that are NOT operated by school-afliated groups (such as PTAs, PTOs, PACs)?
□
Yes
□
No
3. Use of dunk tanks, bounce houses, super slides or other inatable apparatus?
□
Yes
□
No
4. Use or discharge of weapons, reworks or other pyrotechnic displays?
□
Yes
□
No
5. Aerial operations including skydiving, hot air balloons, helicopters, or xed wing aircraft?
□
Yes
□
No
6. Use of animal or motor-driven carts and trailers?
□
Yes
□
No
□
CERTIFICATE OF INSURANCE, ENDORSEMENT PAGE, AND LIABILITY
AGREEMENT (CCF-410 PAGE 2 OF 2) ATTACHED
Certicates of Insurance must be completed as follows according to CCSD Regulation 3613:
1. Name and address on permit must be same as Name of Insured
2. Requesting Organization MUST have physical street address (no PO Boxes)
3. Clark County School District MUST be shown as Additional Insured
4. Ensure that the Additional Insured Endorsement is attached to the
Certicate of Insurance.
5. Certicate Holder MUST be shown as: Clark County School District
4828 S. Pearl St., Las Vegas, NV 89121
CCF-410
Rev. 4/18
Page 1 of 2
CONTROL NUMBER
I have read and understand the Guidelines for Facility Usage by
Non-School Groups, CCSD REG 3613, and if lming, CCSD REG 3613.2
Signature: ________________________Date: __________
Responsible Person (No Digital Signature)
(Because this document is a public record, information you provide
is subject to disclosure upon request pursuant NRS Chapter 239.
However, failure to provide contact information to the District will
result in a denial of a facility use permit.)
For School Site Administrator Use □ Approved □ Denied
Services Requested:
Custodian:
□
Yes
□
No # Requested _______ Start Time ________ End Time _________ Air/Heat:
□
Yes
□
No
School Police:
□
Yes
□
No # Requested _______ Start Time ________ End Time _________ Field Lights:
□
Yes
□
No
Theatre Staff:
□
Yes
□
No
□
Licensed
□
Support Staff Start Time ________ End Time _________
Campus Monitor:
□
Yes
□
No # Requested _______ Start Time ________ End Time _________
Kitchen Worker:
□
Yes
□
No # Requested _______ Start Time ________ End Time _________
(Kitchen Worker: Requestor must complete a CCF-411, Use of Food Service Kitchen Facilities Request Application)
NOTE: It is the school’s responsibility to submit all appropriate work orders for requested services once permits are received.
School Site Administrator (No Digital Signature)
Date
Once complete, email this form along with the Certicate of Insurance, the Additional Insured Endorsement, and non prot letter (if applicable) through
Google E-mail to 0060 Facilities Correspondence Inbox.
For Accounting Department Use
□ Approved □
Denied
Accounting Department Signature Date
□
Prot
□
Non-Prot (Provide non-prot status letter)
Clark County School District
DISTRICT FACILITY USE REQUEST
For Group Use
Requested School Name: _______________________________________________________________ Location Number: ______________
Name of Organization: _________________________________________Responsible Person: ____________________________________
Organization Address
(PO Box Not Accepted): ______________________________ City: ________________ State: _____ Zip Code: _______
Phone/Cell #: _______________ E-mail: ___________________________ Is the Responsible Person a CCSD employee?
□
Yes
□
No
Description of Events: __________________________________________ If yes, what location?: __________________________________
Cost to Participants: _______________ Admission Costs: __________ Estimated number of participants and attendees per hour: _________
Will there be any recording or internet streaming including, but not
limited to, audio, lming, video, or digital types of recording?
□
Yes
□
No
Area Requested: ____________________________________________________ Air Conditioning/Heat Requested:
□
Yes
□
No
Start Date: _____________ End Date: ____________ Day of Week: _____________ Start Time: _____________ End Time: _____________
Start Date: _____________ End Date: ____________ Day of Week: _____________ Start Time: _____________ End Time: _____________
Start Date: _____________ End Date: ____________ Day of Week: _____________ Start Time: _____________ End Time: _____________
This form is only a request until approved by the Accounting Department. Payments are due ten (10) business days prior to the event.
Once payment is received the event will be listed on the Master Event Calendar and a permit will be issued, if applicable. Events not listed on Master
Event Calendar are subject to closure by School Police or other District administrators. CCSD scal year is July 1 through June 30. If your event
overlaps scal years, separate requests are required for each scal year.
NOTE: According to NRS 388.135, members of clubs or organizations which use public school facilities, regardless of whether the club
or organization has any connection to the school, or any pupil shall not engage in bullying or cyberbullying on the premises of any public
school, at an activity, or on any school bus.
