Facilities Use Request Form
Please fill out the form if you would like to use the facilities at Belmont Community School District. By filling out this document, you are assuming all liability for the person, person(s), group(s), or organization(s) using the district’s equipment and or property. In addition, you will assume responsibility for all damages to the facilities and or grounds. You further agree that you will save and hold harmless the Belmont Community School District for and against all claims that may arise due to this activity. You agree to meet with the Maintenance Director, Principal, Superintendent, and/or Food Services Manager to receive instructions on the proper use and cleaning of the district equipment, buildings, and or grounds before and after usage. You will also review a plan for emergencies. You may be issued keys for building use for the activity. You will then be responsible for their safe return no later than three days after the time of usage. If keys are lost, stolen, or not returned, you will be charged by the district the total amount of replacement locks, cores, and or keys of the affected areas of the buildings and or grounds. Finally, you agree to abide by all rules and regulations adopted by the Belmont School & Community Board governing the use of school buildings and grounds.

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Email *
Name of Person Making the Request *
Email Address  *
Phone Number *
Address *
Purpose of Request: What activity or group would like to use the facilities? *
Date(s) Requested to use Building or Grounds *
MM
/
DD
/
YYYY
Beginning Time
*
Time
:
Ending Time *
Time
:
Building or Grounds Area Requested *
Classroom(s) (Please specify below)
HS Commons
HS Library
HS Gymnasium
Elem Gymnasium
Stage
Wrestling Room
Kitchen (specify below if you need oven, dishwasher, cooler/freezer, utensils, etc.
Cafeteria
Tech/Ag Shop
Outside Grounds (specify below)
Row 1
Special Equipment Requested *
Folding Tables
Folding Chairs
Scoreboard
A/V Equipment
Sound System
Coffee Pots
Pitching Machines
Wrestling Mats
Row 1
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