Facility Use Agreement Form

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Facility Requested:*

Full Name of Contact Person/Responsible Party:

Address:*

Mailing Address City State ZIP Code

Telephone Number:*

Alternate Number:

Email Address:*

Organization Name*

Type of Organization*

Submit Proof of Status*

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Date Requested for Facility Use:*

Is this a recurring event?*

Yes

Please describe recurrence details*

Beginning Time Requested*

Hour

Minute

Ending Time Requested*

Hour

Minute

Estimated Number in Attendance*

Description of Event:*

Equipment Requested:*

Overhead Projector

Projector Screen

Internet Access

None

Acknowledgement

Acknowledgement The organization, group or individual applying for the use of the Public Utility District No. 1 of Lewis County's (District) auditorium agrees to save, release, defend, indemnify, and hold harmless the District, its commissioners, officers, employees and agents from any and all claims for injury to person or property arising out of, or in any way connected to its use of the District's meeting facilities except to the extent that any such claims may arise from any negligent act or omission of the District. Further, by signing this application, the undersigned affirms that he/she has read and understood the policies and rules and regulations for the use of the auditorium(s) and agrees to abide by the regulations and limitations therein, including restrictions on the use of public facilities, directly or indirectly for campaigning or any ballot proposition. By requesting internet access the responsible party, group and/or organization understands that users have no privacy rights associated with their use and inappropriate use of the internet may result in the loss of access privileges. Users will not access, download or distribute offensive or illegal material including, but not limited to: pornography; racially or sexually offensive messages; engaging in malicious activities; and messages which are intended to harass or may reasonably be regarded as harassment. Failure to follow the auditorium policies and rules and regulations or misuse of the internet access will jeopardize future use of the auditorium by the user/group. As the responsible party for the event(s) described above, I warrant that I have authority to bind the organization and I agree that I will be on-site during the entire event(s), and I will pay the cost of any cleaning or damage repair to all building facilities, furnishings and/or equipment as deemed necessary by the District. Type Your Full Name to Acknowledge & Agree to All Terms & Conditions Listed Above

Type Your Full Name to Acknowledge & Agree to All Terms & Conditions Listed Above*

I hereby verify the information provided on this form to be true and complete. I understand that by typing my full name below and submitting this information, this form will be stamped with today’s date and authorized by me as if I had signed my signature. I certify under penalty of perjury of the state of Washington that I am the individual named in the electronic signature block.

Auditorium Rules and Regulations*

I have read and agree to the Auditorium Rules and Regulations

Date*

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Facility Use Agreement Form

Acknowledgement

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