Facilities Use: Durham Nockamixon [OUTSIDE GROUP EVENTS]

This is an application for use of the Durham Nockamixon Elementary School by an outside organization Classifications C,D,E & F. An application must be submitted three (3) weeks prior to the event. Please complete the ORGANIZATION ADDRESS completely.

After filling out the form below, be sure to hit SUBMIT when you are finished in order to process your request. 

If you have any questions, please do not hesitate to contact the school or our Athletic Office at 610-847-5131, ext. 2010. 
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Email *
Name of Organization *
Organization's Address *
Organization's Email Address *
State purpose of use (be specific) *
List day(s), date(s), and time(s) requested to use the facility (be sure to specify set up and clean up times):
 *
List area(s) of the facility requested to be used. (Please review the AED Facilities Use Letter here) *
Required
Will an admission fee be charged? *
Equipment Request: Please select the type of equipment requested for your event. Someone will be in touch with you regarding types, quantities and location/placement of equipment. If no equipment is requested, select "NONE."  

NOTE: Livestreaming is NOT provided by Palisades School District on behalf of the organization using district space.
 *
Required
If/when a PSD IT staff member is unable to work an event, the following vendors can be contacted by the requesting party: 
Blue Chip Sound
Joe Pokojni
joe@bluechipsound.com
610-837-8900

City Entertainment Systems
Phil Forchelli
cityent@ptd.net 
610-767-3742

List name, address, phone number and email address of two responsible officials in the fields below: one of whom will be present at the time the facilities requested are being used and who will accept full responsibility for adherence to School District regulations.
Name (1st person making request) *
Address (Street/City/State) *
Phone *
Email Address *
Name (2nd person making request) *
Address (Street/City/State) *
Phone *
Email Address *
I (we) certify that I (we) have read and understand the rules, regulations, AED information, and fee structure of the Palisades School District concerning the use of School Buildings, stadium and turf field as well as the Evening Procedures for Durham Nockamixon School. Further, I(we) forever release the Palisades School District, its directors, agents and employees from all claims, actions and charges whatsoever arising out of the event(s) conducted on the above-mentioned date(s) for which this application is submitted. That upon prompt notice it will defend all actions, suits, complaints or legal proceedings of any kind brought against the Board of Education and any of its agents or employees and further it would hold harmless and indemnify the said School Directors and School District, from any expenses and judgments or decrees recovered against them as a result of the said use of these facilities.
 *
I (we) certify that if I (we) fall into the category of social, civic and recreational meetings and entertainment and other uses pertaining to the welfare of the community, I (we) acknowledge that I (we) will include, “this event is non-exclusive and open to the public without charge” AND “this event is not sponsored by the Palisades School District” on any and all communication or advertising done for my (our) event.
 *
Certificate of Insurance

The organization must submit a signed Disclaimer of Liability and Responsibility for Rented Facilities as well as a certificate of insurance with the following information entered as additionally insured:

Palisades School District 39 Thomas Free Drive Kintnersville, PA 18930

The Disclaimer of Liability and Responsibility for Rented Facilities and the certificate of insurance must be emailed to Tammy Labant: tlabant@palisadessd.org (610-847-5131 x2010)

Ignoring rules or abusing the facility could result in fines and/or loss of access to all of the Palisades School District facilities.

I hereby acknowledge that all the information listed above is true and that I have read and understand the rules and regulations regarding the use of the Palisades School District facilities. By typing your name in the box you are submitting your electronic signature to the Palisades School District:

 *
A copy of your responses will be emailed to the address you provided.
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