1.	Name of Organization In Charge of Event:*

2.	Person Responsible for Arrangements:*

3.	Email Address:*

4.	List Phone number where you can be reached:*

5.	Today's Date:*
	mm/dd/yyyy

6.	Please briefly describe your event.*

7.	Requested Date of Use:* (No more than one month per form)
	mm/dd/yyyy

8.	Time of Use* (Beginning)

9.	Time of Use* (Ending)

10.	Event Start Time:*

11.	Will setup be needed for your event?*If NO, Skip the table below.
	--Please Select--Yes No

12.	Auditorium Equipment:
	Flat Risers   Choral Risers   Tables   Chairs (List #)   Podium Custodial:

13.	Sound Equipment:
	Wireless Mic   Lapel Mic   Wired Mic   CD/Tape Player   DVD/VHS Player   Monitors Sound:

14.	Lighting Equipment:
	Stage Lights   Dimmed House   Spot Light Lighting:

15.	Technology Equipment:
	Laptop   Projected Presentation   Piano   Organ Technology:

16.	Security Required*If Yes, You are responsible for making the arrangements. Please contact Dane Danko at ddanko@westbranch.org or (814) 577-0767
	--Please Select--Yes No

17.	Rental/Custodial fee to be Paid:

18.	Other (Questions, Concerns or Addition Setup Not Listed Above) Please type in the box below. *

19.	We hereby agree to abide by all rules and regulations and make such payments as approved by the Board of School Directors governing the use of said facilities and equipment. We further agree to exercise discretion regarding the use of said facilities and equipment, to make all necessary arrangements for the services of approved personnel, to assume responsibility for damage of school property and equipment, to use only those facilities and areas as stated above, and to assume all responsibility for the actions and conduct of the participants. User holds the school district harmless from all claims for injury to or the death of any person and for damage to or loss of any property arising out of or attributed directly or indirectly to the operations or omissions of the school district. User indemnifies the school district for all damage to property belonging to the school district and for all injuries to the deaths of any representatives or employees of the school district resulting from all acts or omissions or use. The school district is not responsible for user’s property. User must arrange all protective services desired by user. The school district is not liable for the acts or omissions of any protective services engaged by user. The school district may cancel any scheduled events on short notice for district use. (Games, repairs, etc.) PLEASE INCLUDE A COPY OF YOUR LIABILITY INSURANCE FOR YOUR ORGANIZATION.*You must read the above information and check “YES” PRIOR to submitting this form.
	--Please Select--Yes No