Fillable REQUEST FOR FACILITIES USE LOS ANGELES UNIFIED SCHOOL (Los Angeles Unified School District)

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REQUEST FOR FACILITIES USE LOS ANGELES UNIFIED SCHOOL (Los Angeles Unified School District)

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  • 60 check-boxes
  • 116 other fields

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LOS ANGELES UNIFIED SCHOOL DISTRICT 333 S. Beaudry Avenue; 1st Floor LA, CA 90017
Scan/Email to: facilities-use@lausd.net rev
2.1.18
LOS ANGELES UNIFIED SCHOOL DISTRICT
REQUEST FOR FACILITIES USE
Requests must be received no later than 15 Business days before the first day of your requested use.
I. APPLICANT INFORMATION Date: __________________________
Please indicate your organization type below and fill in the required applicant information.
FOR LAUSD SCHOOLS OR OFFICES, PROP 39 /CO-LOCATED CHARTERS (only):
LAUSD School or Affiliated Charter Prop 39 / Co-Located Charter School
LAUSD Board Member or District Offices
School/Office Name:
Mailing Address:
Street Address, City, State and Zip Code
LAUSD Contact Person: E-mail:
Phone: ( ) Fax: ( )
Will this event/activity be co-sponsored by other organizations? YES NO
Please list additional sponsors here:
OTHER APPLICANTS:
Civic or Service Group or one of the following groups: i.e. Boy Scouts, Girl Scouts, Camp Fire Girls,
Good News Club or School Advisory Councils
Other Schools or Private Schools PTA / PTO / Booster Individual
Public or Governmental Agency Religious Organization Company / Corporation
Neighborhood Council Non-profit with 501(c)(3) (Number #_______________)
Off-Season Coach Other (describe) ___________________________
Organization Name or Applicant:
Mailing Address:
Street Address, City, State and Zip Code
Contact Person:
Website:
Driver License or ID#
State where license/ID was issued?
Phone: ( ) Fax: ( )
Cell: ( ) Email:
II. SCHOOL WHERE EVENT/ACTIVITY WILL TAKE PLACE:
a. 1
st
choice _______________________________ School Contact & Title: _____________________________
b. 2
nd
choice*______________________________ School Contact & Title: _____________________________
(*2
nd
choice required only if applying for a recreational permit.)
III. EVENT/ACTIVITY DESCRIPTION
(a) Please mark an “X” in the columns to the right to indicate your responses to the questions
YES NO
1. Will this event occur during school hours?
2. Will any District or Student Body funds be used?
3. Will you charge for the sale of products or fees for services?
If YES, how much per person? $___________ Per day $__________ Per week $__________
4
. Will any fees, admissions or donations be charged or collected for this event/activity?
If YES, how much per person? $___________
What are funds used for? _____________________________________________
For Office Use Only
Date rec’d______________
Reviewer ______________
Date forwarded _________
___CC ___ LASU ___RM
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LOS ANGELES UNIFIED SCHOOL DISTRICT 333 S. Beaudry Avenue; 1st Floor LA, CA 90017
Scan/Email
to: facilities-use@lausd.net
rev
2.1.18
Describe intended event, program or use in detail (Use separate sheet if necessary.) Please attach corroborating
information such as copy of flyer or advertising, list activities, detailed agenda or schedule and event itinerary.
(b) Will any of the items or categories below be a part of the intended event? (Check all activities applicable to your event.)
Animals BBQ Fireworks Fundraiser Festival/Fair/Carnival Inflatables/Jumpers
Childcare/Enrichment Cultural activities Religious services Concert/performances
Recreational sports Recreational camp/clinic Summer/winter/spring camp
Beautification Event (i.e. gardening, tree planting, murals or painting, campus clean-up)
Meetings - Check One: _____ Open to the Public _____Closed to the Public or by invitation only
Topic to be covered: ____________________________________________
(c) Will there be food / food concessions at event? YES NO
If YES,
Pre-packaged food Catering Food Trucks
Other (explain) ____________________________________________________________
IV. REQUESTED DATE(S) / TIME(S): Yo
u may attach additional sheets if necessary.
Event/Program Dates Times
Specify days of use
(i.e. daily, only Mondays)
From: To: From: To:
Date(s):
Date(s):
Date(s):
Rehearsal
Set-up
Tear-down
V. ATTENDANCE: Participants/Spectators:
(a) Number of participants _______________ (b) Number of spectators ______________
(c) Will minors (individuals under the age of 18 years old) be participating in this event?
YES NO
(d) What percentage of participants live within boundaries of LAUSD? _______________
Youth Group Applicants Only:
(a) Has the applicant submitted, along with this application, a list of the group’s representatives who will be on site
during meetings, on this campus(es)? YES NO
(b) The Applicant understands and agrees that the youth group and its representatives are authorized to access
the facility noted in this application but not authorized to access any other areas of the campus.
YES NO
VI. REQUESTED FACILITIES
:
Check all facilities to be used:
•
Indoor Facilities:
Auditorium Classrooms, number of classrooms __________
Cafeteria Dining Area only Library Multipurpose Room
Other (please specify) ____________________________________________
• Recreational
Facilities:
Gymnasium Middle School Gym
(Check appropriate school/gym size if `applicable) High School Gym: Small Large
Football Field Soccer Field Tennis Courts Track Field
Swimming Pool Baseball/Softball Diamond Other _____________________
• Outdoor or
Other Facilities:
Outdoor Lunch Area Playground/Blacktop Quad
Other ________________________________________
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LOS ANGELES UNIFIED SCHOOL DISTRICT 333 S. Beaudry Avenue; 1st Floor LA, CA 90017
Scan/Email to: facilities-use@lausd.net rev
2.1.18
VII. Parking/Parking Operations:
NOTE: Availability of parking or sufficient parking to accommodate your use during any event is not guaranteed and is at the
discretion of the school or District office.
(a) Check all areas to be used for parking: Street Parking Parking Lot Playground / Blacktop
i. Parking will be (check one):
SELF PARKING (no parking operator)
PARKING OPERATOR/VALET COMPANY
ii. If the applicant is not a parking operator, please provide the name of the company providing services
here: ______________________________
(NOTE: Parking operator will also be required to provide insurance.)
iii. Will shuttle services be provided?
YES NO Operator Name (if different from above):___________
(b) Number of cars anticipated? _______________
(c) Will a fee be charged to park?
YES NO
If YES, how much per vehicle? $___________ Per day $______ Per week$______
VIII. Will District equipment be required?
Describe below (Audio visual, lighting, tables, chairs, etc.) YES NO
(Applicant must request the use of furniture and equipment with the school administrator. Additional fees may be required to be paid for rental of
equipment and technical services.)
IX. Insurance Requirements
See page 4 for Standard Insurance Requirements which are subject to change. Actual insurance requirements will
be determined by the nature and scope of your event or activity.
By signing below, the Principal, Administrator or applicant represents that the information provided in this Request for
Facilities Use is true and correct. Misstatements, misrepresentations or omissions may cause cancellation, delay or
refusal of this facilities use request.
FOR LAUSD School/Office/Prop 39/
Co-located Charters events
PRINCIPAL / ADMINISTRATOR SIGNATURE:
FOR OTHER APPLICANT SIGNATURE:
Signature and Date
Signature and Date
PRINT NAME and TITLE
PRINT NAME and TITLE(if applicable)
Name of School or Office
Name of Organization
Forward your completed Request for Facilities Use form as follows:
Scan and email to: facilities-use@lausd.net
OR
Mail or walk-in application to:
Los Angeles Unified School District
Permit Office
333 S Beaudry Avenue, 1st Floor
Los Angeles, CA 90017
Business Hours: 7:00am to 4:00pm
Should you have any questions, please contact:
Los Angeles Unified School District Permit Office
213-241-6785
213-241-6900
PLEASE BE ADVISED THAT COMPLETION OF THIS FORM AND/OR ACKNOWLEDGEMENT OF RECEIPT OF THIS REQUEST
FOR FACILITIES USE DOES NOT CONSTITUTE APPROVAL OR PERMISSION TO MOVE FORWARD WITH YOUR USE.
After the initial review of this completed Request for Facilities Use form, your request will be forwarded to
the Division of Risk Management or LAUSD Permit Office for further handling.
Additional documents and fees may be required by these offices prior to formal approval of your request.
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333 South Beaudry Avenue, 28
th
Floor, Los Angeles, CA 90017
riskfinance@lausd.net- Telephone (213) 241-0329 – Fax (213) 241-8956 – TTY (213) 241-6882
2.1.18
Los Angeles Unified School District
STANDARD INSURANCE REQUIREMENTS
The District requires that all vendors, contractors, professional service providers and other entities that associate
with the District comply with requested insurance requirements and provide evidence of insurance certification.
All applicants shall, at their own cost and expense, procure and maintain the following coverage during the entire
period of use of the premises and / or facilities and all deductibles or Self-Insurance Retentions (SIR) shall be
declared in writing and all deductibles and retentions above $25,000 require District approval.
Commercial General Liability Insurance, including both bodily injury and property damage, with limits as
follows:
$1,000,000 per occurrence
$
50,000 fire damage
$
5,000 med expenses
$1,000,000 personal & advertising injury
$2,000,000 general aggregate
$2,000,000 products/completed operations aggregate
Business Auto Liability Insurance for owned, scheduled, non-owned or hired automobiles with a
combined single
limit of no less than $1,000,000 per occurrence. If no company or organization autos
will be used, then an Auto
Liability Statement must be completed.
Workers’ Compensation and Employers Liability Insurance in an amount covering full liability under
the California
Workers’ Compensation Insurance and Safety Act and in accordance with applicable
state and federal laws.
Part A - Statutory Limits
Part B - $1,000,000/$1,000,000/$1,000,000 Employers Liability
Sole proprietors or organizations with no employees are exempt from providing Workers’
Compensation and Employers Liability Insurance, but must provide a signed Workers’
Compensation Statement.
Abuse and Sexual Molestation coverage (applicable when youth are involved in any capacity)
$1,000,000 per occurrence/$1,000,000 aggregate
The Certificate Holder portion of the insurance certificate must be listed as follows:
Los Angeles Unified School District & the Board of Education of the City of Los Angeles
333 South Beaudry Ave, 28th Floor
Los Angeles, CA 90017
Additional Insured Endorsement
The Commercial General Liability policy and the Commercial (Business) Automobile policy must contain an
additional insured endorsement in favor of:
“Los Angeles Unified School District and the Board of Education of the City of Los Angeles”
***********************************************************************************************************
THE ACTUAL INSURANCE REQUIREMENTS WILL BE DETERMINED BY THE NATURE AND SCOPE
OF THE ACTIVITY AND IS SUBJECT TO CHANGE.
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REQUEST FOR FACILITIES USE LOS ANGELES UNIFIED SCHOOL (Los Angeles Unified School District)

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Completed 21 August 2021

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