Organization Making Request	Building Requested
Name of Responsible Individual	Date(s) Requested
Address of Responsible Individual	Hours of Use
Telephone No.	Expected Attendance
Purpose of Facility Use	Addmission Charge YES NO

Circle Area(s) Requested:

Auditorium Gymnasium

Cafeteria Playground

Classroom(s) Other

Lecture Hall

Circle Equipment Requested:

Tables Sound/Lighting*

Chairs Spotlight*

Microphone* Piano

Other

*Requires operators at additional charge

Rental Fees total is an estimate based on information given prior to use of the facilities. Additional charges may result after use of facilities.

Custodial Fees reflect the need for custodial hours and include a minimum charge of one hour before and one hour after the event.

Rental Fees:

Auditorium Gymnasium Other

$ $ $ $

Custodial Fees:

$

Total Amount Due (30) Days in Advance of Approved Date(s): $

Note: The use of school facilities is subject to existing policies and regulations and, as school purposes are primary, the school authorities reserve the right to cancel any contract.

I accept responsibility for fee(s), supervision, damage and compliance with the building use requirements of the Lexington Public Schools.

Signature Telephone No. Date

Approve: Yes / No

Head Custodian: Date:

Principal: Date:

Director of Facilities: Date:

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