EmailMe Form - Non-GSOC Facilities Use Agreement

Responsible Adult in Charge: *

First Last

Address: *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone: *

### - ### - ####

Email Address: *

(please re-enter email to confirm):

Troop or SU Number: *

Beginning & End Dates of Activity: *

Must provide beginning date and end date of activity (example 01-01-17 to 12-31-17):

Activity Location: *

Name of School, Facility or Company.

Activity Location (i.e. school district &/or additional information): *

NAME OF SCHOOL DIST, if facility is not a school advise more facility details here.

Activity:

Brief description.

Originals: *

Originals NOT required by facility.

Originals ARE required by facility.

Forms will be signed by GSOC & copies will be emailed to Applicant. ORIGINALS will be held in file unless required by facility & requested by applicant - we are trying to save paper, postage and time.

Do you need a Certificate of Insurance (COI): *

YES

NO

Please answer yes or no. If unsure check no, as in many cases the facility has our Certificate of Insurance on file. Then add a note in Special Notes section below stating "COI unsure".

If COI CONTACT information is different enter here:

Regarding COI Request - if facility & contact information is different than the information provided in uploaded forms please fill in contact information here.

Any Special Notes to Facility Department Processing your Forms:

File Upload: Tips - scan all pages into one document. There is only one upload per application.

It is important to include ALL forms & information necessary to expedite the process. Blank or incomplete forms will delay the process.

Signature: *

Clear

By submitting this form, I confirm that the information in this form is correct to the best of my knowledge.

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