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BETHEL SCHOOL DISTRICT <br />LANE COUNTY NO. 52 <br />4640 BARGER <br />EUGENE, OREGON 97402 -1297 <br />FAC =L=TY USE APL =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 />applications are valid only for the current school year, unless approved for long term use <br />by the school board. I p <br />FACILITY REQUESTED RM&WAy S/,hon�1_�' Aie pf(^t VIM ANTICIPATED NUMBER OF PARTICIPANTS <br />*Name of organization applying 6+' `d V41w,Q ' , pQ�}/�ij 5f 0 MA, 5V9& PM 4 <br />If this application represents a retiLgest Trom an Age cy or oxiganization 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 />*Name and address of person submitting application �'y (/1"rQlrLe"',� <br />4 <br />•Single meeting YES NO Date of meeting De C 8 ry ,74 h (�-5 Time of meeting 7 130 GOB <br />•Series o YE NO *Time a//n��d dates of meeti <br />[Time span needs to include preparation and clean -up. Attach separate list of dateh /uses, <br />if needed.] <br />•Admission to be charged? YES ( NO Adults $ Chi ldren/students $ <br />(r <br />Proposed activity: 6 +i kAS '�V t5'P, C_&M _ , IW L &A M& <br />Members only YES NO Members and invited friends YES NO <br />Area(s) of building to be used: Gym [J Classroom(s) [] <br />Media Center [j Playground complex [j Other G Q �� <br />APPLICANT SIGNATURE 1" <br />13ILLING ADDRESS _?17 <br />Public in general YE NO <br />Cafeteria [] Kitchen [J <br />N. <br />rersei 1 51Z- <br />331P -9335- - <br />DATE "f S J WORK PHONE S'T ' a.` (�' �p HOME PHONE 0 -1 -� 7 b <br />BILLING INFORMATION <br />NO CHARGE <br />hours $$ ll 4 <br />CLASS I II III IV Facility charge x - = l� 00 <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 L3 <br />(FEES TO BE COLLECTED AT BUILDING LEVEL MAKE CHECKS PAYABLE TO: <br />AND FORWARDED TO CENTRAL OFFICE) BETHEL SCHOOL DISTRICT <br />Building <br />administrator <br />signature Date <br />WHITE COPY - Retained in building YELLOW C04Y - Business Office PINK COPY - Applicant <br />