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~ <br /> SETHEL SCHOOL DISTRICT _ <br /> LANE COUNTY NO. 52 ~ ~ ~ ~ Z-( <br /> 4640 SARGER <br /> EUGENE, OREGOII 97402-1297 '~~j~~Y <br /> FAC=L=TY USE APPL=CAT=ON ~N~-I-l~ <br /> <br /> prospective users of Bethel School District facilities are required to complete thi-s-/ <br /> applicatio» and submit it to the office of the building they want to use. Approved <br /> applications are valid only for the current school year, unless approved for long term use <br /> br the school board. r <br /> l1wCILITY R~OESTBD ~ / ANTICIPATBD DER Olr PARTICIPAlITS <br /> •Kame of organization apply, q ~ t" ~l',J'X'7 ~ ;-~r!C;,, <br /> If this application represents a request rom n agency r organ zat on w a a o ce <br /> (Girl Scouts, Boy Scouts, Ridsports, U of O, L.C.C., etc is an administrator or supervisor <br /> avrtare and supportive of this request? YES NO <br /> •llame and address of person submitting application { I.- I ~ l IC ~ ~i~,~-=.~ }S'Ui~,[ <br /> •Single meeting i~ NO Date of meatiaq 7 ~ ~ v 3 Time of meeting ~ ~c+ - ~ ~3~ <br /> •8eries of meetings .YES (AiO,~ •Time and dates of meetings <br /> J <br /> [Time span needs to include preparation and clean-up. Attech~ep ~ /uses, <br /> its needed. j <br /> Q (~V b <br /> •lldmission to be charged? YES (Ndr Adults ~ ChildBa~RR/ $~de <br /> Proposed activity: r+~ <br /> nbers only YBS NO Members and invited friends YES No Public in general NO <br /> Area(s) of building to be useds Gym Classroom(s) [J Cafeteria [j Kitchen [J <br /> M~1dia Center [j Playground complex [j Other [j <br /> t a , <br /> ApPLICAIIT SI~IATURE t?i..`;... , z l <br /> App ant S t0 t61'~B ~ rn @S on reverse <br /> SII.LIIIG ADDRESS S r ~ v V ~ i t r f~ - a I< ! C ¢ <br /> D1?T8 ! j ~ a ~ Ii~ORK PHO1fE ~ L't ' ~ ~ G ~ PBANE <br /> ~Illlllllllllilllllllllillllllillllilllllllllllllllillillllilllllillillllilillllllllllllllll <br /> BILLING INFORMATION <br /> 110 CBAR,GE <br /> hours <br /> CLASS I II III..' IV Facility charge x = . <br /> Supervisor charge x = <br /> (See Administrative Rule ECAA) Kitchen charge x = <br /> Custodial charge x = <br /> Maint./set-up charges x = <br /> ADDTL. energy charges x = <br /> Maintenance or supply charges = <br /> TOTAL CHARGES <br /> DES TO BE COLI.ECTBD AT BOILDIIIG LEVEL MAKE CHECKS PAYABLE TOs <br /> ~ To cs11TRAL grFlcs) 88TH$L SCHOOL DISTRICT <br /> Building <br /> administrator-._ ` r~ ~ <br /> signature , ; ~ . ~ 1. ~y-- Date j . r. <br /> Ifrl'18 COPY - I1~tain~d ~n bu11d1ny YSbLON CQPY - Budnsa• O!lica PIlIIC ODPY - 1?pplicaat <br /> <br />