JULIAN CHARTER SCHOOL, Inc.

PO Box 2470 ● Julian, California 92036

APPLICATION AND PERMIT

FOR THE USE OF JCS FACILITIES

Name of Organization
Address
Contact Person	Email Address	Telephone Number

Facility Requested:

Central Office	JCS-Manzanita	JCS-Pine Hills Madison	JCS-Pine Valley
JCS-Cedar Cove	JCS-Mountain Oaks	JCS-Pine Hills Vallejo	Other: ____________________________

Type of Facility to be Used:

Multipurpose Room	Field:
Classroom	Other (specify): ____________________________

Date(s) Requested:

Date:	Time:	am/pm to	Time:	am/pm
Date:	Time:	am/pm to	Time:	am/pm
Date:	Time:	am/pm to	Time:	am/pm

Equipment Needed (specify): __________________________________________________________________________

Purpose of Event:	Expected Attendance:
Will food/beverage be served?	Yes	No
Will any admission fee, collection or solicitation of funds be involved?	Yes	No

If so, please describe: ________________________________________________________________________________

__________________________________________________________________________________________________

STATEMENT OF INFORMATION AND AGREEMENT

The undersigned states, that to the best of his/her knowledge, the school property for the use of which application is hereby made will not be used for the commission of any act prohibited by law and/or for the commission of any crime(s) including, but not limited to, the crime(s) specified in Sections 11400 to 11401 of the California Penal Code. I certify under penalty of perjury that the foregoing is true and correct.

I further certify that I shall be personally responsible, on behalf of my organization, for any damage sustained by the school building or furniture accruing through the occupancy of said building by my organization. I agree to conform to the California School Code and to all the rules and regulations of the Julian Charter School governing the use of the school buildings.

Applicant's Signature:________________________________________________________________

IMPORTANT: Application, Certificate of Insurance, and fees must be complete and submitted to the JCS Office ten (10) working days prior to the event. Do not advertise or promote said event until all site and administrative approvals are complete.

FOR JCS USE ONLY RENTAL AND USE FEES	Note: Make all checks payable to Julian Charter School _________________________________________________________ _____________________ Site Administrators Approval (If applicable)	Title	Date _________________________________________________________ _____________________ Director (or Designee) Approval	Title	Date