Request for Use of Institutional Facilities
Facility will not be reserved until all paperwork has been submitted (no later than ten working days prior to the date of
intended use). This includes this Facility Use Form and insurance verification.
Name of Public Agency or Non-profit Group requesting facility:
Address: City: State: Zip Code
Name of Individual(s) in charge: Phone #: Co-sponsor(s):
Facility Requested: Proposed Date(s): Setup Time:
Actual Event Beginning Time: Actual Event Ending Time:
General liability insurance carrier & policy #
INSURANCE MUST BE PROVIDED BY ALL OFF-CAMPUS ORGANIZATIONS (Copy of policy must be attached)
Yes No
Amount $
Admission Charge
(For Office Use) Fee charged by LCC for activity if applicable: Amount $
Tables
#
Security
Other
(Specify)
Chairs
#
Extra trash cans/liners
Podium
P.A. System
Set-up
In accordance with the established policies and procedures of LCC and the State of New Mexico, the Facility User agrees to:
1. Assume responsibility for security of areas and facilities being used. (Recommendation for amount of security will come from the Office of Campus
Security. Cost for security will be the responsibility of the First Party, but shall not be effective until both parties have reached a mutual agreement.)
2. Assume cost for vandalism or damage occurring during activities.
3. Adhere to all LCC rules and regulations including regulations of the particular facility used.
4. Indemnify and hold harmless LCC, it's Board of Trustees, agents and employees, individually and collectively from and against all costs, losses, claims,
actions and judgments, which may be made by the undersigned, their assignees, heirs and personal representatives or anyone else as a result of any
injury or damage which may be sustained while participating in said activity.
5. Adhere to all State and Federal laws relating to illegal drugs, alcohol, and weapons.
6. Maintain the General Liability Insurance of the greater of the limits in New Mexico Tort Claims Act or $1,000,000 for the duration of the activity or
per the NMPSIA TULIP insurance.
Violation of prohibited activities will be grounds for summary cessation of scheduled activity.
Name of Individual
Requesting Facility
Date
Signature of Individual
in Charge
APPROVAL: LCC Director
of Facilities
Date
FINAL APPROVAL:
LCC PRESIDENT
Date
Date
Print on Golden Rod Paper
Enter information below, print, sign and submit to Physical Plant Department
Brief description of activity:
