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Midway R-I School District- Facility Use Request
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* Indicates required question
Email
*
Your email
Date Facility is needed
*
MM
/
DD
/
YYYY
Day of the Week
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Group/ Sponsor
*
Your answer
Usage start time
*
Time
:
AM
PM
Usage end time
*
Time
:
AM
PM
If request is for a regular weekly/monthly time, please describe.
Your answer
Location/area being requested
*
Your answer
Door Access Needed
*
Please choose all doors that you will need unlocked.
Main Doors (North)
Elementary Library Door (NE Elementary)
Dock Loading Door (South East by Kitchen)
Elementary Playground Door (Far East end of the building)
Commons Door (South)
Hall of Fame Door (SW side of the gym)
High School West Door (Far North West end of the building)
Not-Applicable
Required
Estimated Attendance
*
Your answer
Name of primary contact person
*
Your answer
Address of primary contact person
*
Your answer
Phone Number of primary contact person
*
Your answer
Name of secondary contact person
*
Your answer
Address of secondary contact person
Your answer
Phone number of secondary contact person
*
Your answer
Will the group need access to the building to decorate or set-up before the time/day of the use?
*
Yes
No
Admission standards for the event:
*
Tickets Required
Invitation Only
Open to the Public
Do you anticipate guest with special needs/physical challenges?
*
Yes
No
Will food be served?
*
Yes
No
Is special room set-up required? (a separate/additional charge may apply)
*
Yes
No
Will there be a need for a custodial service after the event? (separate/additional charge may apply)
*
Yes
No
Will outside equipment be delivered/picked up?
*
Yes
No
Is audio visual equipment needed (separate/additional charge may apply)
*
Yes
No
Please send a copy of you certificate of liability to
Option 1
Clear selection
Name and Date of Person Filling Out This Form
*
Your answer
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