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Hutchinson Field Facility Use Request
This permit authorizes the use of Hutchinson Field. The person to whom this permit is issued agrees to accept responsibility for the care of
the facility and the compliance with school board policy covering facility use by nonschool groups. (Policy KG)
Start Time:
*
End Time:
*
Date(s) Needed:
*
Day(s) of the week:
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Estimated Attendance:
*
Admission Charged:
*
Please select
Yes
No
Special Needs:
(Microphones, lecterns, tables, etc.)
Purpose of Facility Usage:
*
Person to Whom Issued:
*
Address to send invoice to:
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Organization:
Phone Number:
*
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###
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Email
*
Confirm
Custodian Fee:
Comments:
Deposit:
Balance Due:
Renters will be responsible for and will be required to reimburse the school district for any damage to school district property as a
result of using school facilities.
Insurance Required:
Please select
Yes
No
A Certificate of Insurance in the minimum amount of $500,000 naming Pittsburg USD 250 as additionally insured must be
provided. If your insurance specifies “Damage to Rented Premises” you must show a minimum $500,000 for each occurrence.
Pittsburg USD 250 does not assume any liability of accidents occurring to participants or other individuals during schedule events;
nor does the District assume responsibility of equipment left on the premises by outside organizations.
This form must be completed by the person to whom it is issued and presented by that person to the custodian on the date(s) shown.
Please read all the provisions and guidelines related to this agreement.
I have read the FACILITY USE AGREEMENT and RULES and I agree that I will be responsible for full compliance with them.
Please enter your full name.
Date
MM
/
DD
/
YYYY
Approval:
Comments:
Approved By:
Date Approved:
Amount of Payment Received:
Date of Payment:
The USD 250 Emergency Contact During Your Event is:
USD 250 Emergency Contact Phone