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. 






  

















6005.3 Facilities Use Form                                                                Page  of 2