WAYNE HIGHLANDS SCHOOL DISTRICT

        USE OF SCHOOL FACILITIES

             REQUEST AND AGREEMENT FORM

Please read the attached pages, complete all information on this page and return this page to the appropriate school principal. Please keep the attached pages for your reference.

Requesting Organization/Individual:____________________________________

Address:_________________________________________________________

Telephone Number(s):______________________________________________

Contact Person:___________________________________________________

Address:____________________________________________________

Telephone Number(s):_________________________________________

Facility Requested:_________________________________________________

Description of Activity:

Equipment/Services Requested:_______________________________________

Dates and Hours of Requested Use:___________________________________

Charging Admission Fee:            Yes            No            Amount:_________________________

Requesting Waiver of Fees:

            a. Rental:                        Yes            No – Amount:$_______________

            b. Custodial:                   Yes            No – Amount:$_______________

_______________________________                       _____Approved            _____Denied

Signature – Contact Person                                   

________________                                                            __________________________

Date                                                                               Principal Signature and Date