Indian Hill Exempted Village School District

6855 Drake Road	Cincinnati, Ohio45243 APPROVINGAUTHORITY

FACILITIES REQUEST FORM

Date of Form: ______________________

A. Name of Organization: Boosters PTO IHPA IH Rec Scouts Foundation Other ___________________________

________________________________________________ Contact Person:_____________________________________

Address:

Phone:	(______)	Email:

B. Building Requested:	__

Portionof buildingto beused: ____________________________________________________________________________

C.	Date(s) Requested	From (Time)*	To (Time)*	Hours

Be sure to include time for set-up and clean-up: Specify time access needed

1.

2.

3.

4.	_____________________	_____________________

D. Number of persons usingfacility (eachdate): 1.	,2.	,3.	,4.	_

E. Purpose(s)forwhich facility isto beused_____________________________________________________________________________

F. Food - If involved, specify (for safe cleaning purposes):__________________________________________________________________

G. Special lnstructions:	__

H. This organization is a (check one) Resident or Non-resident group	and	(check one) profit or non-profit group. (Resident Groups are those which have a majority of their members residing within the legal boundaries of Indian Hill School District.

I.	Designated Representative I Please Print

I,_______________________________________________________,agreetoactas Designated Representative, as defined inthe Indian Hill Boardof Education Policy regarding Public Useof School Facilities ("Board Policy")for the organization above in connection with this application. I am acting as Designated Representative with the knowledge, approval and consent of the organization.
I have read and I understand the Board Policy as well as the School Facility Rules and Regulations. The organization agrees to abide by its terms which are incorporated herein by reference.

Attached hereto isa certificate of Insurance indicating that the organization is currently covered bya liability insurance policy naming the Indian Hill Exempted Village School District ("District"), the Indian Hill Board of Education ("Board"), allindividual members of the Boardand all agents and employees of the District andthe Board as additional insureds.

I agree to follow the School Facility Rules and Regulations attached with this page.

Email:____________________________________________	Signed:___________________________________________

Address:	_

APPROVAL: (See Item "B")

Auditorium Coordinator

Athletic Director

District Calendar Coordinator

Phone(s):___________________________________________ Home	Cell	Business

Date:	                             		Date: Building Principal

Date:	                             		Date: _____________ Assistant Principal

Date: