Request for use of building I hereby request use of the at the

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Point Pleasant Beach, New Jersey 08742
I hereby request use of the at the

(Room/Location) (School/Building)


(Date/Dates) (Day/Days of Week)

Request this location from to

(Include time for set-up/clean-up) (Hour) (Hour)

Name of Event
Time of Event to

(Hour) (Hour)

Organization Name
Organization Address/Phone Number

Please describe the activity you are proposing for this room or building:

Anticipated number of attendees: Age group:

Insurance Policy# Company

Note: A certificate of insurance and endorsement naming the Board of Education of Pt. Pleasant Beach as an additional co-insured must be received before the start of use.
An insurance policy is in effect for this use. The liability limit is $
Is the group exempt from user fees? Yes No

Will admission be charged? Yes No

Proceeds will be used for the following purposes:
Name and phone number of person/persons who will be present at the school/building and in charge of group:

(Name/s) (Phone #)

(If others are to be in charge as well please list their names and home phone numbers on the reverse side of the form indicating the dates and times that they will be in charge.)
Custodial Services are needed from to

(In accordance with Board Policy, user groups will be billed for custodial services.)

Name/address for bill to be mailed:

Do you need any additional services?

(video equipment, chairs, etc.)

Board of Education Office Use Only

High School Principal Approved Not Approved

Antrim Principal Approved Not Approved

Supv. Extra Curricular Activities Approved Not Approved

Supv. Operations/Maintenance Approved Not Approved

Superintendent Approved Not Approved

Board of Education Approved Not Approved
Approval Date

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