PIEDMONT REGIONAL EDUCATION PROGRAM

Application for Use of School Facilities

Applicant Information

Name of Organization:

Authorized Agent:

Phone:

Fax:

Contact Person:

Phone:

Fax:

Current address:

City:

State:

ZIP Code:

School/Site Information

School/Site:

Space(s) to be used:

Date(s) to be used:

Beginning Time:

Ending Time:

Total Hours:

Number of Participants Approximately:

Other Event/Activity Information

Specify the purpose for use of space:

Equipment or Food-Service needs (specify):

Is Organization non-profit?

Insurance Requirement: Each applicant is required to carry a minimum of $1,000,000 in liability insurance coverage for all School Facilities activities. A certificate of Insurance will be required. Please attach a copy of your Certificate of Insurance.

Applicant Agreement

1) We will be responsible for payment of the rental fee upon approval by Building-level Principal. Fees will be calculated based on the chart on page 2.

2) This permit may be canceled by the Executive Director or designee at their discretion

3) That we become responsible for any and all damage to the site, building, and/or equipment, for the duration or the time(s) and date(s) listed on the application and understand that we will not be permitted to use the school property again if we fail to undertake these measures

4) That we agree to indemnify and hold harmless the Regional Board/Albemarle County School Board, and all of its officers, employees, and agents from any and all claims demand, suits causes of action, or judgments any person had, now has or may have in the future against the event which is the subject of this agreement

Monthly payment or rent:

5) The Regional Board/Albemarle County School Board is not liable for anything we do or sponsor while using these facilities

6)This organization has an open membership policy and does not discriminate on the basis of race or sex

7) We understand that smoking and alcohol use are prohibited on school property

8) We will restrict usage to assigned areas and observe contracted time limits

9) We will obtain prior approval before any signs, placards, or banners are erected on school property

Signature

Authorized Agent Signature:

E-mail:

Date:

Signature of co-applicant:

E-mail:

Date:

 

 

Eligible Organizations

The following designations classify various organizations and groups for the purposes of establishing priority for use and for the charging of fees

 

Type I Organizations

 

School and School Division sponsored organizations for activities related to School Division programs or business;

 

Associated organizations, such as PTOs/PTAs and Booster Clubs, for activities supporting School Division programs;

 

Youth organizations, such as Boy Scouts, Girl Scouts, YMCA, and 4-H

 

Clubs for programs, meetings and activities that do not require a direct fee for participation in such activities;

 

Local Government agencies and departments for programs and activities serving citizens;

 

Virginia High School League for District and Regional athletic events; and

 

 

Type II Organizations

Organizations focused on youth activities

 

Type III Organizations

 

Other fee-based programs and other activities by organizations not covered by Types I and II,

Community and civic associations.

 

 

COMMUNITY USE OF SCHOOL FACILITIES FEE SCHEDULE

 

For Office Use Only

Calculation

Site Manager/Custodian

$24.00/hr

Food Services Staff

$24.00/hr

AV/Lighting Technician

$24.00/hr

High School Auditorium (requires Lighting Tech)

$40.00/hr

Central Elementary & School Board Auditorium

$30.00/hr

Library

$25.00/hr

Classroom

$15.00/hr

High School and Middle School gymnasium

$40.00/hr

Elementary and Auxiliary gymnasium

$25.00/hr

Cafeteria

$25.00/hr

Synthetic Turf Field

$50.00/hr youth $100/hr other

Competition Grass Athletic Field

$35.00/hr

Practice Field

$10.00/hr

Additional Fees

Description:

Subtotal of fees

Late payment fee (if any)

Total Fees Due

Cancellation of a rental must be done at least three (3) business days before the rental. Cancellation later than three (3) business days will result in the renting organization being assessed three (3) hours rental fee and three (3) hours personnel fees.

Office Use Only

1st Personnel Need:

2nd Personnel Need:

Fax:

 

Employee name:

Employee name:

 

Application is Recommended for □ Approval □ Denial by Principal Signature

 

Applicant Notified of Recommendation by: Date:

 

Application is:

 

□ Approved □ Denied

Superintendent/Designee: Date:

 

The Piedmont Regional Education Program Board does not discriminate on the basis of race, color, ethnicity, religion, age, national origin, marital status, disability, sex, status of a parent, or any other legally protected status in the provision of employment services, programs, activities or treatment. The Executive Director is designated as the responsible person (Compliance Officer) regarding assurances of nondiscrimination. Any complaint alleging discrimination based on a disability shall be directed to the Executive Director, who may be reached at the following address: 1434 Rolkin Court, Suite 201, Charlottesville, VA 22911; telephone (434) 975-9400. The Piedmont Regional Education Board is an Equal Opportunity Employer.