Room(s) Requested _____________________________________________________________________________________________________
Dates Desired __________________________________________________ to _____________________________________________________
Nature of Use __________________________________________________________________________________________________________
Estimated Attendance: Number of Participants _________________ Number of Spectators _________________
Will an Admission Fee, Collection, or Solicitation of Funds of any type be involved? Yes ________ No ________
If “Yes”, for what will the proceeds be used? __________________________________________________ Amount per person?_______________
Will food or beverages be served or sold at this event? Yes ________ No ________
Special Equipment, services, personnel needed:
Custodian for ______ hours Facility Supervisor for______ hours Groundskeeper for Playing Field for______ hours
Tennis Courts to be: Lighted ______ Unlighted ______
Other special equipment, services or personnel needed: _________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Name of Group / Organization ___________________________________________________________________ Profit ______ Non Profit ______
Organization Address _____________________________________________________________________ Phone _________________________
Authorized Representative _________________________________________________________________ Title ___________________________
Home Address __________________________________________________________________________________________________________
Home Phone _______________________________________________ Work Phone _________________________________________________
I understand that the use of college facilities must be in accordance with the rules and regulations of the West Valley-Mission Community College District, including
possibility of cancellation, should the facilities be needed for the educational program. I further understand that in connection with the use of facilities the organization
named above is to pay the West Valley-Mission Community College District as stipulated.
The above-named Organization and its members shall be held responsible for any and all loss, accident, neglect, injury or damage to person, life or property which
may be the result of, or may be caused by the Organization’s occupancy of the facilities or premises, and for which the District might be held liable. The Organization
shall protect and indemnify the District, the Board and/or any officer agent or employee of the District and save them harmless in every way because from all suits or
actions at law for damage or injury to persons, life or property that may arise or be occasion in any way because or the occupancy of the facilities or premises,
regardless or responsibility or negligence. The applicant agrees to furnish such liability or other insurance for the protection of the public and the District as the
District may require.
Authorized Signature _____________________________________________________________________________________________________
I have read, understand, and agree to the regulations and requirements as stated above.
______________________________________________________________________________________________________________________
Certificated of Insurance naming West Valley-Mission Community College District as an additional insured and Certificate Holder
Required ________ On File ________
