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Clover Park School District

Facility Use Application

Certificate of Insurance: The user shall procure at its own expense, a Comprehensive General Liability insurance policy, naming the district as an additional insured. This policy shall be primary and written with limits of: $1,000,000 Combined Single Limits, per occurrence.

Coverage shall include but not bre limited to: Broad From Property Damage • Products/Completed Operations • Blanket Contractual. Coverage cannot be cancelled or reduced in coverage without thirty (3) days written notice to the district. A Certificate of Insurance evidencing coverage and a copy of the endorsement naming the district as an additional insured must be submitted to the district business office prior to the event.

The proof of insurance must accompany this form before the application will be processed.

To insure adequate processing time, requests should be submitted 30 days prior to date requested.
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Ongoing activity - Days of activity (check): S M T W TH F S For week(s)
Open to public? Yes Np
Will there be an admission fee, collection or funds solicited? Yes Np

Other equipment: It will be the responsibility of the applicant to provide other equipment such as overheads, screens, TV monitors, easels, etc. The building principal, his/her designee or media center specialist may be able to help you with your needs, but that must be arranged personally.

The applicant hereby agrees to abide by the laws of the State of Washington, the County of Pierce, the City of Lakewood and by the regulations of the Clover Park School District. It is understood and agreed by the applicant that this permit may be revoked or cancelled at any time with or without cause. It is further agreed that the applicant agrees to protect, indemnify and save harmless Clover Park School District and its officers and employees from any and all claims, liabilities, damages, or rights of action directly or indirectly growing out of the use of the premises covered by this application. The applicant furthermore agrees that attendance will be open to the public.

All applicants may be held responsible for any expenses incurred by the district arising from the use of a facility. In the event of damage, each applicant agrees to pay promptly the district’s statement of amount due.

Authorization: I hereby warrant and certify that I am the authorized representative of the organization/individual named above, that the statements are true to the best of my knowledge, and that our organization and I agree to be bound by the regulations and policies governing the rental use of Clover Park School District facilities.

DISTRICT USE ONLY
Custodial Hours Required
 

User Priority List
In the event of a scheduling conflict, the following prioritized list will be used when considering user requests:

1. School district related activities
2. Student related activities
3. Community enrichment activities
4. Businesses/profit-making organizations
Payment Method

Please make check out to:
Clover Park School District
and submit to:
Recreation & Facilities Department
Clover Park School District
10903 Gravelly Lake Dr SW • Lakewood WA 98499
Telephone: (253) 583-7364
Terms: Net 30 days

DO NOT DISTRIBUTE - SEND ALL COPIES TO RECREATION/FACILITIES
Distribution: White - Recreation/Facilities Canary - Applicant Pink - Worksite Administrator