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BETHEL SCHOOL :DISTRICT <br />LANE COUNTY NO. 52 ' <br />4640 BARGER��'+ <br />EUGENE, OREGON 97402 - 1297'('' <br />F'ACIL =TY USE APPL =CAT =ON' <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 />1 applications are valid only for the current school year, unless approved for long term use <br />by the school board. <br />FACILITY REQUESTED {�. � l✓ +C, k&/ ANTICIPATED NUMBER OF PARTICIPANTS <br />•Name of organization applying <br />If this application represents 'a requ st from an agency or organizati — with .local office <br />(Girl Scouts, Boy Scouts, Kidsports, U of o, L.C.C., etc.), is an administrator or supervisor <br />aware and supportive of this request? YES NO <br />•Name and address of person subm �( <br />itting application 'r'��ia <br />•Single meeting YES NO Date of meeting APPAL � <;�C) (� Time of meeting ��� )C) <br />�.. " <br />1 •Series of meetings YES r Nd eTime and 'Oates'of <br />i <br />[Time span needs to include preparation and clean -up. Attach separate list of dates /uses, <br />if needed.] <br />•Admission to be charged? YES (NO)' Adults $ Children /Students $ <br />Proposed activity: dAc <br />Members only YES NO Members and invited friends YES No Public in general (YE0 NO <br />) g Gym [) ) [) [) �] <br />Area(s) of building to be used: G Classroom(s) Cafeteria .Kitchen <br />Media Center [) Playground complex {) Other °) ('c 'r €r €(_9t I <br />APPLICANT SIGNATURE L <br />[Applicant agrees to terms & rules on reverse] <br />FILLING ADDRESS <br />DATE rJ 1 �. WORK PHONE la t i." d �` HOME PRONE (? t 8 1 <br />BILLING INFORMATION <br />NO CHARGE <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 t c ` i <br />(FEES TO BE COLLECTED AT BUILDING LEVEL MAKE CHECKS PAYABLE TO:. AND FORWARDED TO CENTRAL OFFICE) BETHEL SCHOOL DISTRICT <br />Building <br />administrator <br />P {� <br />signature Date } 111 <br />WHITE COPY - Retained in building YELLOW CONY Business Office PINK COPY Applicant <br />