Fillable Facility Request Form 0 (East Central Community College)

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Facility Request Form 0 (East Central Community College)

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East Central Community College does not discriminate on the basis of race, color, religion, national origin, sex, age, or qualified disability in its educational programs and activities, employment
practices, or admissions processes. The following persons have been designated to handle inquiries regarding the non-discrimination policies of East Central Community College: Inquiries
regarding compliance with Title VI, ADEA, and Title IX coordinated by Dr. Teresa L. Mackey, Vice President for Instruction, Walter Arno Vincent Administration Building, Room 171, Post Office Box
129, Decatur, MS 39327, Phone: 601-635-6202, Fax: 601-635-4011, tmackey@eccc.edu. Inquiries regarding compliance with Section 504 and ADA coordinated by Dr. Randall Lee, Vice President
of Student Services, Eddie M. Smith Student Union, Room 201, Post Office Box 129, Decatur, MS 39327, Phone: 601-635-6375, Fax: 601-635-3247, rlee@eccc.edu.
FACILITY REQUEST
ACTIVITY / MEETING ROOM REQUEST
REQUESTED BY:
TELEPHONE:
ACTIVITY:
DATE SUBMITTED:
DATE(S) NEEDED:
TIME(S)
From:
AM PM
NEEDED:
To:
AM PM
PARTICIPANTS:
NUMBER TO BE ACCOMMODATED:
BUILDING:
ROOM(S):
ROOM ARRANGEMENTS
EQUIPMENT NEEDS
Classroom Style U-Shape Style
Round
Table
Style
Other
Style
No. of Tables No. of
Chairs
Laptop Internet Connectivity LCD Projector
TV/DVD/VCR Sound System/Podium
Columns/Lattice Panels Other: ___________
Registration
Table
RefreshmentTable(s)
FOOD ARRAN
GE
M
EN
T
S
MEALS: (The College Food Service Provider must be used for
events that involve the serving of food)
Yes No Tablecloths Needed (charge
applied)
REFRESHMENTS: (The College Food Service Provider must be
used for events that involve the serving of food)
Yes No
SERVING TIME:
AM PM
ADDITIONAL NEEDS: (i.e. tablecloths, tables, etc. –
additional charge may apply)
EXTERNAL GROUPS – (IF APPLICABLE)
CHARGE INCURRED: HOLD HARMLESS AGREEMENT/RELEASE FROM LIABILITY:
Yes No Amount: $ Yes No
AUT
HO
RI
Z
AT
ION
Event Sponsor Representative
DATE:
ECCC Representative
DATE:
A signed copy of rules/regulations must accompany this request form.
DISTRIBUTION:
President’s Office Vice President for Public Information Ed Girling
Vice President for Student Services Director of Physical Plant
Aladdin Food Management Services
Vice President for Instruction Director of Information Technology
Vice President for Business Operations Dean of Student Services
1. The Contracting Organization/Individual assumes responsibility for the preservation of order in the
College facility(ies) being utilized. Uniformed Police Officers must be provided, as deemed appropriate
by the Vice President for Student Services, for all activities/events by those renting the College facilities.
The College may provide this service for an additional fee.
2. Smoking is prohibited in all College facilities.
3. The Contracting Organization/Individual assumes any and all liability for damage to the facility(ies)
being used for an activity/event as well as property damage or loss of College property. Further, the
Contracting Organization/Individual agrees to promptly pay, on demand, for any damage(s) or loss of
property that occurs before, during, or after the scheduled activity/event.
4. The Contracting Organization/Individual understands that the use of the College’s approved food
service provider is required for events held on the campus of ECCC that involve the serving of food.
5. The Contracting Organization/Individual hereby accepts responsibility for the enforcement of
Mississippi code, Section 67-1-37, sub-section (g), which prohibits the sale or consumption of alcoholic
beverages in or on the campus of any public college.
6. The Contracting Organization/Individual hereby accepts total responsibility for the payment of all
royalties or other fees which might become due to any third party because of the performance of any
drama, musical composition, or other copyrighted work.
7. No permit for use of College facilities will be granted if the purpose or result of such use is personal
gain to any individual or individuals or of a political or sectarian nature.
8. Permission to utilize College facilities for an activity/event shall be revocable and shall not be
considered as a lease.
9. No pianos, movie or video equipment, scenery or other apparatus are to be moved into a College
facility unless special permission is granted.
10. Persons and/or organizations who use their own equipment or properties and which they consider
valuable, must remove said equipment immediately after the performance unless special permission is
given. The College will not be responsible for any equipment left in the facility(ies).
11. Official College Representatives shall at all times have free access to all parts of the facilities.
Representatives reserve the right to revoke any meeting permit should the action be deemed necessary
or desirable and in the best interests of ECCC.
12. The college, at its discretion, may require organizations filing an application for use of College facilities
to submit details of the program and/or participants. Also, additional regulations specific to the
campus/center or College facility(ies) utilized may be attached to this form and will be considered
applicable.
I HEREBY CERTIFY THAT I HAVE READ THE ABOVE RULES AND
REGULATIONS AND ACCEPT ALL RESPONSIBILITIES THEREOF.
________________________________________ ________________________
Signature Date
East Central Community College does not discriminate on the basis of race, color, religion, national origin, sex, age, or qualified disability in its educational programs and
activities, employment practices, or admissions processes. The following persons have been designated to handle inquiries regarding the non-discrimination policies of East
Central Community College: Inquiries regarding compliance with Title VI, ADEA, and Title IX coordinated by Dr. Teresa L. Mackey, Vice President for Instruction, Walter
Arno Vincent Administration Building, Room 171, Post Office Box 129, Decatur, MS 39327, Phone: 601-635-6202, Fax: 601-635-4011, tmackey@eccc.edu.
Inquiries regarding compliance with Section 504 and ADA coordinated by Dr. Randall Lee, Vice President of Student Services, Eddie M. Smith Student Union, Room 201,
Post Office Box 129, Decatur, MS 39327, Phone: 601-635-6375, Fax: 601-635-3247, rlee@eccc.edu.
$500.00 (No tape, staples, etc. on stage,
$100.00
$100.00
$ 50.00
$ 75.00
Pavilion Dick Livingston Walking Trail $ 75.00 (No cooking in the pavilion)
Auditoriums
floor, chairs, or walls)
Student Activity Center
South Campus Gymnasium
Classrooms
East Mall Area
Banquet Rooms $ 50.00 (If food is served there is no
charge for banquet rooms.
(Aladdin Food Management Services
must be utilized for all food service.
East Central Community College does not discriminate on the basis of race, color, religion, national origin, sex, age, or qualified disability in its educational programs and
activities, employment practices, or admissions processes. The following persons have been designated to handle inquiries regarding the non-discrimination policies of East
Central Community College: Inquiries regarding compliance with Title VI, ADEA, and Title IX coordinated by Dr. Teresa L. Mackey, Vice President for Instruction, Walter
Arno Vincent Administration Building, Room 171, Post Office Box 129, Decatur, MS 39327, Phone: 601-635-6202, Fax: 601-635-4011, tmackey@eccc.edu.
Inquiries regarding compliance with Section 504 and ADA coordinated by Dr. Randall Lee, Vice President of Student Services, Eddie M. Smith Student Union, Room 201,
Post Office Box 129, Decatur, MS 39327, Phone: 601-635-6375, Fax: 601-635-3247, rlee@eccc.edu.
RELEASE FROM LIABILITY
I, ______________________________________ (the individual) hereby release,
waive, and discharge East Central Community College from any and all liability to the
individual, or legal representatives, for any and all loss or damage, and any claim or
damages resulting from participation in the activity identified below. Further, I,
_____________________________ (the individual) hereby release, waive, and
discharge East Central Community College from any and all liability related to damage
of College property resulting from participation in the activity identified below and
hereby agree to be responsible to remedy any damages sustained to College property
resulting from participation in the activity identified below.
Witness my signature on this ______ day of ________________________, 202____.
_________________________ ______________________________
Signature of Individual Signature of Witness
----------------------------------------------------------------------------------------------------------
Description of Activity: ___________________________________________________
______________________________________________________________________
______________________________________________________________________
Group Responsible for activity: ____________________________________________
Date(s) of Activity: __________________________________
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Facility Request Form 0 (East Central Community College)

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Completed 26 July 2020

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