Booking Form. Please complete the booking form and return it to:

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Dominick Baldwin
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Booking Form Please complete the booking form and return it to: PerthModernSchool.FacilitiesHire@education.wa.edu.au Questions? Please contact the Facilities Hire Coordinator on (08) 9380 0560.

1 Booking Form Please complete the booking form and return it to: Questions? Please contact the Facilities Hire Coordinator on (08) Please note that your event is not confirmed till you receive approval and confirmation from the Facilities Hire Coordinator, this includes a signed copy of the agreement. Name of Company / Community Group ABN Registered Business Name This Business is registered as: Registered with ASIC Yes No Sole Owner Yes No Public Liability The User must during the term and continuation of this Licence effect, maintain and keep current with an insurer authorised by the Australian Prudential Regulation Authority to conduct insurance business in Australia to the satisfaction of the Minister the following insurances: Public liability insurance covering the liability for claims arising out of the use or occupation of the Premises and/or Equipment for a minimum amount of $5 million for any one occurrence (see appendix B for information on appropriate insurance coverage). It is NOT possible to book an event at Perth Modern School without a public liability insurance. If an insurance policy is held details of the insurance policy are recorded below: Name of Insurer Policy Number Date of Expiry Do you have any paid employees? Please attach a copy of your Insurance Certificate. Yes No If YES The User must during the term and continuation of this Licence effect, maintain and keep current with an insurer authorised by the Australian Prudential Regulation Authority to conduct insurance business in Australia to the satisfaction of the Minister the following insurances: Workers Compensation insurance in accordance with the provisions of the Workers Compensation and Injury Management Act 1981 (WA), including cover for common law liability for an amount of not less than $50,000,000 for any one event in respect of workers of the User. Name of Insurer Policy Number Date of Expiry Please attach a copy of your Insurance Certificate. Updated October 2018 Page 1 of 5

2 Event Name Event Description Date(s) Expected Numbers Attending: Time(s) Bump in: Time performance: Bump out: Venue AV Light & Sound Engineer For events in the Auditorium you are entitled to our IT/AV light and sound engineer (max 3 hours). Please indicate start and end time. Additional hours can be paid for separately at a cost of $50 per hour. Start time: End time: Contact Name Contact Phone Contact Postal Address (inc postcode) Keys & Codes issued to: (1 sets of keys) Code Signature Mobile Contact Updated October 2018 Page 2 of 5

3 Area for Hire Concert Facilities: Includes the Beasley Auditorium (capacity max 300 x p), an area for the service of afternoon tea during an intermission or before / after performance (dinner), usage of large kitchen, toilet facilities, sound and lighting technician (max 3 hours), cleaning and Indicate by below $1,045 per event (max 7 hours) Beasley Auditorium: Includes the Auditorium (capacity max 300 x p), toilet facilities, sound and lighting technician (max 3 hours), cleaning and $920 per event (max 7 hours) Rehearsal: Short rehearsal (no use of sound or light), no cleaning, with toilet facilities and $120 per hour (max 2 hours) Piano use in Beasley Auditorium: Includes compulsory tune $300 piano hire Embleton Music Block: Includes toilet facilities, cleaning and Andrews Building: Central area and toilets, includes cleaning and Andrews Building: Rooms - Includes toilets, cleaning and $65 per room, per session (max 4 hours) Stokes Building: Includes central area, toilets, cleaning and Stokes Building: Rooms - Includes toilet facilities, cleaning and $65 per room, per session (max 4 hours) Parsons Building - Lecture Theatre: Includes AV equipment in lecture theatre for max 100 x people. Please bring own technician / IT person. includes use of Refectory sitting area, toilet facilities, cleaning and $400 per session (max 4 hours) Parsons Building - Refectory Sitting Area: Includes toilet facilities, cleaning and $235 per session (max 4 hours) Reunions: Areas as required, clean included. Free under auspice of Modernians, prior approval needed Tyler McCusker - Old Gymnasiums 1 & 2 (Boys / Girls): Includes toilet facilities, cleaning and parking $65 per gym, per session (max 4 hours) Updated October 2018 Page 3 of 5

4 Area for Hire Tyler McCusker - Gym 1 (New): Includes parking, cleaning and toilet facilities Indicate by below $1,000 per event (max 7 hours) dependent on equipment required Volleyball - per court, per hour (3 courts available) Basketball / Netball - per court, per hour (1 court available) Badminton - per hour (9 courts available) Office Use Only This section will be completed by the School and returned to you for approval. Quote - A quotation will be forwarded to you by reply . Session is defined as: Max 4 x hours per session (classrooms / TMSC - Old Gyms) Max 7 x hours per event (Auditorium / TMSC - New Gym) Terms of Payment: Payment cleared in advance of first date of hire. Area for Hire Cost Total Updated October 2018 Page 4 of 5

5 Equipment Additional Equipment Hire / Access Request Urn hire $20 per item Free: 5 microphones inc stands (only 5 channels available in sound desk) Free tables (max 10) Free chairs (max 100) Alcohol licence Additional Equipment Supplied by User I wish to confirm the booking as stated in this Application for Hire for Facilities, Terms and Conditions I have read and agree to comply with all Terms and Conditions of this booking in addition to those as shown in the Licence. For and on behalf of the User Name: Signature: Date: Mobile No: By signing, I give permission for my details to be given to Education Security as the person to contact during the period of hire. Information included on the Application for Hire for Facilities, Terms and Conditions and Conditions of Use as stated in the Licence for Use of Property Vested in the Minister for Education (Section 6B of the Education Act is supplied in good faith and is correct at time of print. However, at times, due to circumstances beyond our control, situations may change and you will be advised accordingly and as soon as possible. Updated October 2018 Page 5 of 5

This Business is registered as: Registered with ASIC Yes No

This Business is registered as: Registered with ASIC Yes No Booking Details Please complete and return to: PerthModernSchool.FacilitiesHire@education.wa.edu.au Questions? Please contact Mica Pereira 9380 0560 (Mon, Wed and Friday) / Micaela.Pereira@education.wa.edu.au