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BETHEL SCHOOL DISTRICT PO:"" <br />LANE COUNTY NO. 52 REC: <br />4640 BARGER YQ AM: <br />EUGENE, OREGON 97402 -1297. <br />,FAC I L;= TY US E AP%"= CAT g O1� <br />- :. Prospective .users of.. Bethel. School District facilities are required to complete this." <br />application.. - 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 />by the school board. <br />:.YACILITY REQUESTED A aw V" ANTICIPATED NUMBER OF PARTICIPANTS <br />*Name of organization applying C.AA21. vi �iUelQ,lil,pi Par l Q,L 1/ 11/I Dln <br />If this application represents a re4uett fit6m an agency or organization with a local office <br />(Girl Scouts, Boy Scouts,,Kidsports, U of 0; L.C.C., etc.), is an administrator or supervisor <br />aware and supportive of this request? YES NO <br />i 11 <br />•Name and address of person submitting application 1IIQ �(/�gl <br />I 11P ooseAr <br />•Single meeting XtR) NO Date o meeting - 14 - . - ) - Oi l Time of meeting - -$'�00 PA <br />•Series of meetings. YES NO *Time and dates of meetings <br />[Time span'needs to include preparation and clean -up. <br />if..needed..] " <br />@Admission to be_ charged? YES o Adults $ <br />Proposed activity:._ kc <br />Attach separate,list of dates /uses, <br />Children /students $ <br />, IVIAJ ,>n� Pail ( M <br />Members -only YES NO Members- and,invited friends YES NO Public in general (� NO <br />Area(s) of building to be used: -Gym [J Classroom(s.) [] Cafeteria [] Kitchen [J <br />Media Center [1' Playground complex [ J Other <br />t <br />I5�4a <br />• "APPLICANT SIGNATURE <br />- [Alb plicant agr s to terms & ru.tes on revex- <br />PILLING ADDRES <br />DATE ��`/ ` . ( I WORK PHONE J I - E7 HOME PHONE <br />BILLING INFORMATION <br />NO CHARGE <br />hours $$ L{ VO <br />CLASS I II. III IV Facility charge x "3 = <br />Supervisor charge <br />(See Administrative Rule ECAA) Kitchen charge <br />Custodial charge <br />Maint: /set -up charges <br />ADDTL. energy charges <br />Maintenance or suunly charges <br />(FEES TO BE COLLECTED AT BUILDING LEVEL <br />AND FORWARDED TO CENTRAL OFFICE) <br />Building <br />administrator.: <br />signature. <br />x = <br />x <br />x = <br />x = <br />x = <br />TOTAL CHARGES ' O <br />MAKE CHECKS PAYABLE TO: <br />BETHEL SCHOOL DISTRICT <br />Date <br />WHITE COPY - Retained in building YELLOW COP <br />Y ° Business Office PINK COPY - Applicant <br />