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SOUTHERN CONNECTICUT STATE UNIVERSITY 501 CRESCENT STREET, NEW (Southern Connecticut State University)

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SOUTHERN CONNECTICUT STATE UNIVERSITY
501 CRESCENT STREET, NEW HAVEN, CT 06515
FACILITIES USAGE FORM
This form and related materials (if any) must be submitted to the Facility Administrator at least 15 days prior to the proposed event.
Acceptance of this request does not constitute approval. Reservations are confirmed subject to requirements and policies of SCSU.
Refer to the definitions on the reverse side as you fill out this form.
PART I: USER INFORMATION: To be completed by the requestor THIS FORM MUST BE TYPED
1. TODAYS DATE:
2. DAY OF EVENT:
3. DATE OF EVENT:
4. TIME IN:
5. TIME OUT:
6. EVENT TIME:
7. ANT. ATTEND:
8. FACILITY:
9. ROOM NUMBERS:
10. UNIVERSITY OR OUTSIDE ORG.:
11. ORGANIZATION NAME:
12. CONTACT PERSON, ADDRESS AND TELEPHONE NUMBER:
13. EVENT DESCRIPTION:
15. ADMISSION OR REGISTRATION CHARGES:
16. TICKETS AVAILABLE AT:
17. TICKET PHONE:
18. ALCOHOLIC BEVERAGES: (IF “YES” A UNIVERSITY ALCOHOL POLICY MUST BE OBTAINED FROM THE FACILITY ADMINISTRATOR)
YES NO
19. FOOD SERVICE: (IF “YES” CAMPUS ORGANIZATIONS MUST COMPLETE A REQUEST FOR FOOD SERVICE FORM)
YES NO
20. FUND / ACCOUNT TO BE CHARGED:
21. AUDIO VISUAL EQUIPMENT:
22. SPECIAL INSTRUCTIONS:
AS FACULTY ADVISOR OR REQUESTER FOR THE ABOVE ORGANIZATION, WE AFFIRM THAT WE ARE FAMILIAR WITH AND AGREE TO ABIDE BY THE POLICIES
GOVERNING THE USE OF UNIVERSITY FACILITIES. WE ALSO AGREE TO ACCEPT RESPONSIBILITY FOR ANY DAMAGES, LOSS OR THEFT OF UNIVERSITY EQUIPMENT
AND PROPERTY, INCLUDING ALL CHARGES INCURRED.
WE ALSO AFFIRM THAT WE WILL BE ON SITE AT ALL TIMES WHEN THE RESERVED FACILITY IS IN USE.
23. FACULTY ADVISOR’S NAME, CAMPUS ADDRESS AND CAMPUS EXTENSION:
SIGNATURE OF REQUESTER
DATE
SIGNATURE OF FACULTY ADVISOR
DATE
SIGNATURE OF APPROPRIATE DATE
DEAN / VICE PRESIDENT / PRESIDENT
PART II: SUPPORT SERVICES: To be filled out by the service providers
1. UNIVERSITY POLICE: assignment #1
ACCOUNT NUMBER:
1. UNIVERSITY POLICE: assignment #2
ACCOUNT NUMBER:
1. POLICE REPEAT:
2. CUSTODIAL STAFF: assignment #1
ACCOUNT NUMBER:
2. CUSTODIAL STAFF: assignment #2
ACCOUNT NUMBER:
2. CUST. REPEAT:
2. CUSTODIAL STAFF: clean-up
DATE:
ACCOUNT NUMBER:
2. DAY CUSTODIANS TO CLEAN AFTER EVENT:
YES NO
3. OTHER STAFF:
4. SPECIAL INSTRUCTIONS:
5. ATTACHMENTS
YES
NO
N/A
6. ADMNISTRATORS’ INITIALS
FOOD SERVICE
FACILITY
ALCOHOL POLICY
STAFF
NON-PROFIT STATUS
POLICE
SIGNATURE OF FACILITY ADMINISTRATOR
DATE
INSURANCE
MAINTENANCE
DATE FORM RECEIVED:
AIR-CONDITIONING
Part 1
1. Today’s Date.
2. Day/Date of Event. Please include both day and date (i.e. Saturday, January 23, 1993)
This form may be used to reserve several days at one time provided that:
a. The use is for the same purpose and time each day.
b. No support services are required on any of the requested days (i.e. police, food,
custodial, air-conditioning, etc.)
3. Time In. Time you wish to enter the facility.
4. Time Out. Time you expect to relinquish use of the requested facility.
5. Event. Time of event’s start if different from the time in.
6. Anticipated Attendance. The number of people you are expecting to attend or to participate at your
event. Please be accurate as this figure is used for the assigning of all overtime personnel.
7. Facility. Name of the building you are requesting. If you require the use of several facilities on
campus, a separate Facilities Usage Form should be prepared for each facility.
8. Room Number(s). Example: Engleman 135
9. University Organization or Outside Organization. Check the appropriate box. All outside users
must contract with SCSU for the use of facilities.
10. Organization Name. Full name of organization. No acronyms, please.
11. Name of Contact Person. Complete address and telephone number should be included
12. Event Description. Description of your planned use of the facility. In the case of a performance or
presentation, please be specific about the title, groups or individuals being presented.
14. Admission or Registration Charges: If yes, indicate the amount.
16. Alcoholic Beverages. Events where alcohol is sold or distributed require adhering to specific
University policies available from the Facility Administrator.
17. Food Service. As indicated, food service must be ordered through the University concessionaire for
most facilities. Food cannot be sold or distributed on campus by independent contractors or individuals.
18. Fund/Account to be Charged. Indicate the University account where charges must be coded. (i.e.
General, Auxiliary, Extension, Student Activity, etc.) .
19. Audio Visual/Television Services. Be specific in your needs. The Facility Administrator will
forward your request for these materials to the AV/TV Office. Leave blank if you contact the AV/TV Office
directly.
20. Special Instructions. Indicate all special arrangements for the event (i.e. podium, chalkboard, room
set-up, etc.)
21. Faculty Advisors. Name, Address and telephone number should be included.
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SOUTHERN CONNECTICUT STATE UNIVERSITY 501 CRESCENT STREET, NEW (Southern Connecticut State University)

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Completed 24 July 2020

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