OFFICE OF ADMINISTRATIVE SERVICES
Facilities Use Request for Classrooms by
UH Affiliated Faculty, Staff, and Student Organizations
(For theatre rental, contact directly at 455-0380)
The use of Leeward Community College facilities is governed by policy approved by the University of Hawaii
Board of Regents. These practices and procedures govern the short-term occasional use of campus facilities,
including campus grounds and parking lots by organizations with and without university affiliation.
All requests must be submitted no later than 2 weeks prior to function date to allow review, authorization and
scheduling. Do not publicize event until you have received proper clearance. Failure to follow this schedule may
result in this request being denied. By your signature on this form, the user agrees that all facilities use will be left
in the same condition as before use (i.e. tables and chairs rearranged for a function must be restored to
original set-up, white boards erased, lights turned off, etc.) before leaving.
User category:
1. Registered student organization:
__________________________ / _______________________
(Name of Organization) (Signature of faculty advisor & campus ext.)
Print Name: _____________________________
2. Faculty or Staff organization:
____________________________ / ________________________
(Name of Organization) (Signature of faculty advisor & campus ext.)
Print Name: _____________________________
3. College-recognized organization with the primary purpose of providing service or support to the college:
________________________ / ____________________ Print Name: __________________
(Name of Organization) (Signature of faculty advisor & campus ext.)
Department/Division Chairperson (Print Name: ___________________________________________)
Authorized Signature:
__________________________________ Date: _____________________
Purpose of Event:
______________________________________________________________
Purpose of Use: Public Welcomed?
____ Estimated Attendance? _____ Fees? _____ Amount? ________
DATE(S) REQUESTED:
__________________________________________________________
DAY(S) OF THE WEEK IN USE (CHECK ALL THAT APPLY):
SUN MON TUES WED THURS FRI SAT
TIME OF USE:
_________________________________________________________________
TYPE OF FACILITIES NEEDED:
____________________________________________________
REQUEST: APPROVED / DISAPPROVED
Remarks: (Complete both pages before submitting to AD-112)
NOTE: Computing and/or Audio/Visual equipment should be secured
through your own division office or user’s organization.
Request for additional folding tables & chairs should be submitted to
Operations & Maintenance via a work request.
________
William K. Akama III
Leeward Community College
Office of Administrative Services – Facilities Use
FACILITY ASSIGNED: ___________
Special Set-up Needs:
___________
Open By:
______ Close By: ______
Copies to: Applicant Custodial Security Other:
___________________________
Facilities Use Request Page 1 of 1 Version 4.28.2014
Print Form
Facilities Use Practices & Procedures
1. Dances which are sponsored by a Leeward Community College approved organization must pay for and
provide a minimum of one uniformed Honolulu Police Department officer to oversee event. One faculty
advisor must also be present for the entire activity.
2. Organization requesting use of Leeward Community College Cafeteria must either pay custodial overtime
to clean-up after event or may elect to organize within their own organization an ad-hoc clean-up
committee. If an ad-hoc committee is formed, one representative must clearly be in charge and
responsible for clean-up. This includes making sure to remove all flyer/signs taped up on walls or glass
windows, picking up rubbish and properly bagging and disposal of rubbish in dumpsters. If the
organization elects to use Leeward Community College custodial services for cleaning, a deposit of
$40.00 should be enclosed, check made payable to Leeward Community College.
3. If any organization wishes to be able to consume alcoholic beverages on-campus, they must first obtain
written approval through the Chancellor’s Office and submit approval along with the “Facilities Use
Request” form. If no written approval is attached, alcoholic beverages are prohibited from being
consumed or distributed.
4. If you are requesting use of the Leeward Community College Theatre, please contact Theatre Manager at
455-0380 for proper approval forms and regulations.
5. Facility users must understand and agree to restore facilities and/or rearrange furniture back to the
original set-up before leaving. Otherwise are subject to additional fees and/or penalties.
NOTE: Failure to follow these rules may result in future requests being denied.
I
______________________________ have read the above rules and regulations for facilities usage and
agree to abide by it.
Signature:
________________________________________ Date: _________________
Facilities Use Request Page 2 of 2 Version 4.28.2014
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome