Facilities Use and Event Request Form

Transcription

1 CONTACT INFORMATION Organization Name: Contact Name: Billing Address: Facilities Use and Event Request Form Phone Number: Fax Number: Address: Do you have a relationship with Mansfield University (faculty, staff, student, alumni or other)? If sponsored by Mansfield University, indicate department or organization: Is your organization tax exempt? Tax exempt #: Has this event occurred in the past? If so, what was the date? EVENT INFORMATION Event Title: Event Description (as much detail as possible): Preferred Date Event Begins: Preferred Time Event Begins: Preferred Date Event Ends: Preferred Time Event Ends: If flexible, please list other date/time options: If longer than one day, please describe timeframe and events within (as much detail as possible):

2 ATTENDEE INFORMATION Estimated number of attendees: Will staff and/or attendees arrive early? Estimated number of authorized adults: If yes, how many and date/time? What are the ages of the participants? If participants are under the age of 18, certify that this event meets one of the below exemptions: Event is open to the general public, which minors attend at the sole discretion of their parent/legal guardian. Private event where minors attend under parental or legal guardian supervision. Event that meets all requirements as found in the University s Protection of Minors Policy. HOUSING & DINING NEEDS Housing availability dependent on date and rate dependent on event type. Will your event be requesting housing? If yes, what is the approximate number of beds? How many of these rooms do you expect to be singles? Linens one (1) pillow with pillowcase, one (1) flat sheet and fitted sheet, one (1) blanket, and two (2) towels. Will your event be requesting linens? If yes, what is the approximate number of sets? Meals availability dependent on number of participants and rate dependent on event type. Will your event be requesting meals in the main dining area? If yes, what is the approximate number of meals requested? Breakfasts (list each date) Lunches (list each date) Dinners (list each date) Will your event be requesting any catered meals? If yes, please list date(s) and meal(s) (B-L-D, Reception) you wish to have catered: The information provided above regarding meals is to allow us to gauge the needs for your event. Once needs are established, it is your responsibility to contact Dining Services and/or Catering.

3 FACILITIES & SERVICES NEEDS Indicate the type and number of spaces REQUIRED for the proposed event. Provide details in the space provided. If you would like access to additional spaces as optional for your participants, please also list those in the details. Facilities Services Classroom: Conference Room: Computer Lab: Auditorium/Theatre: Large Meeting Space: Breakout Meeting Space: Field Space: Gymnasium Space: Swimming Pool: Recreational Space (ping-pong, billiards, etc.): Rock Wall/Low Ropes/High Ropes: Kitchen Area: Fire Pit/Ring: Other: Tables: Chairs: Media Cabinet: Podium: Projector and Screen: Teleconferencing: Whiteboard: Smartboard: Wireless: Sound/Light System: Other: Additional costs may occur for the above (or if audio visual, custodial or other personnel are needed) and will be reflected in your quote/facilities Use Agreement.

4 PARKING/POLICE SERVICE NEEDS Will your event be requesting parking? If yes, what is the approximate number of spaces requested? Handicap spaces? Loading, unloading and parking during the event shall be in the designated areas assigned ONLY. Please note, spaces may be limited. Will your event be requesting traffic/crowd control? If yes, please describe what is needed: TRANSPORTATION NEEDS Will your event be requesting transportation? If yes, please describe how you intend to use the transportation: PRINTING NEEDS Will your event be needing printing for the event (signage, handouts, etc.)? If yes, please describe what is needed? The information provided above regarding printing is to allow us to gauge the needs for your event. Once needs are established, it is your responsibility to contact Printing Services. ADDITIONAL INFORMATION Please provide any additional information, special needs, and specific details about your group: INSURANCE AND CLEARANCE DISCLOSURE The sponsoring organization shall provide a Certificate of Insurance covering property damage liability and bodily injury in which Mansfield University, the Pennsylvania State System of Higher Education, and the Commonwealth of Pennsylvania are included as additional insured (no less than two hundred fifty thousand dollars ($250,000.00) per person and one million dollars ($1,000,000.00) per incident) and a letter of assurance of non-discrimination before the University commits the use of its facilities. The sponsoring organization shall ensure that activities including minor children (under age 18) are properly supervised. The following adult to child ratio must be maintained at all times: one adult (21 years+) per 6 children 5-10 years of age, one adult (21 years +) per 8 children years of age. The sponsoring organization is responsible for ensuring supervision ratios are maintained at all times during the event and will be responsible for communicating all rules and regulations to the group.

5 The sponsoring organization shall also provide certification as evidence that all adult employees and adult volunteers who have direct programmatic interaction with minor children during the event have satisfactorily completed all required clearance checks (PA State Criminal Record, PA Child Abuse History Clearances, and FBI Fingerprint Background Check) and have been trained on policies and issues related to minor safety and security.