Request for use of grounds/fields

B19.1

POINT PLEASANT BEACH SCHOOL DISTRICT

Point Pleasant Beach, New Jersey 08742
REQUEST FOR USE OF GROUNDS/FIELDS
I hereby request use of the ________________________________at ________________________________

(Field/Grounds – See Attached Map) (School/Building)

On ___________________________________ _______________________________________________

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

Request this location from _______________________to__________________________________________

(Hour) (Hour)

Name of Sport/Event_______________________________________________________________________
Time of Sport/Event_____________________to__________________________________________________
Please describe the sport/activity you are proposing for this field or grounds:____________________________
_________________________________________________________________________________________
Organization Name/Address/Phone Number_____________________________________________________
________________________________________________________________________________________
Number of teams/players:________________________ Age group:___________________________________
Coaches names and phone numbers:___________________________________________________________
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 on the field/grounds 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?

(Bathrooms, lights etc.)
Requested times and locations cannot be switched or changed without Board Approval

B19.1 – Page 2

Board of Education Office Use Only

Miscellaneous Comments

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 Permit # Field #

Approved April 28, 2009