Port Washington Public Schools Use of Facilities Application PWUFSD Facilities and Operations Administrative Annex 90 Avenue C Port Washington, NY 11050 Attention: M. Rutigliano 767-4940 Fax 767-4949 Please complete this form no later than 15 days and no sooner than six months prior to date requested and submit to address above. Approved permit must be produced upon request to school officials during the course of the event. Date Application Submitted ORGANIZATION INFORMATION 1. Name of Organization Contact Person 2. Is organization non-profit? Yes No If yes, attach IRS form 5099(a) or 501(c)(3) and IRS letter. 3. Attach a copy of organization s membership list with addresses. 4. Attach a copy of organization s constitution or statement of purposes if this is first application. ACTIVITY INFORMATION 1. Facility Requested Date, Day of Week, Hours Requested 2. Title of Event/Activity 3. Will food or beverages be sold or consumed? Yes No If yes, list nature of refreshments 4. Will admission or other fee be charged? Yes No Fees may not conflict with District Policy or State Law. 5. a. If any proceeds are derived, for what purpose will they be used? b. Person responsible for reporting receipts and expenditures Name SPECIAL NEEDS 1. Will special equipment be needed (public address, lighting, projector,etc.)? Yes No If yes, list type of equipment 2. Will storage of equipment belonging to organization be necessary? Yes No If yes, list nature and amount of equipment to be stored and length of time storage needed 3. Will kitchen facilities be needed? Yes No Kitchen attendant required at additional fee (see rates schedule attached). SUPERVISION 1. Approximate attendance anticipated Residents Non-residents 2. Approximate number of Adults Minors. Each 20 minors must be supervised by an adult at least 18 years old. 3. How many people will have supervisory responsibility? Please list: Name Address 1227 8/12
READ REQUIREMENTS BELOW AND RETURN SIGNED APPLICATION TO: PWUFSD Facilities and Operations, Attn: Marian Rutigliano Administrative Annex 90 Avenue C Port Washington, NY 11050 Port Washington School District Facility Use Requirements The use of all District facilities shall be subject to the approval and rules of the Board of Education administered by the Office of Facilities. 1. Organizations wishing to use District facilities shall first apply to the Office of Facilities. 2. In the event of inclement weather, the Director of Facilities has the final authority on whether facilities are usable. 3. Intoxicants shall not be brought onto District facilities at any time. 4. All posted rules must be adhered to. 5. Profanity, objectionable language, disorderly acts or illegal activities of any kind are absolutely prohibited, and those violating this prohibition will be ejected from the premises. 6. Any damage to District facilities shall be promptly repaired at the user s expense. No exceptions. If maintenance personnel are not available, make sure all doors are locked and lights are turned out when leaving. 7. Permits may be revoked at any time. 8. Any organization with youth under 18 years old requires the presence of adequate adult supervision at all times. 9. An advance payment equal to 20% of the total cost must be provided upon approved application. 10. A public telephone is located in Weber Middle School (in the hallway outside the Boy s Athletic Office), and in Schreiber High School (in the Main Lobby). The non-emergency telephone number for the police is 516-883-0500. If using Guggenheim school call police at 516-883-3100. Non-emergency telephone for fire is 516-883-2200. 11. Smoking or other use of tobacco products is not allowed on District property. 12. Facilities are not available if in conflict with school use. No unauthorized vehicles are allowed on school property. No field or building alterations (lining of fields or gymnasiums, erecting permanent goal posts or structures, etc.) are allowed without prior approval. 13. The District does not discriminate on the basis of race, color, national origin, religion, physical impairment or sex in its educational programs or employment services. 14. All users must provide the following insurance prior to using facilities. I. The policy naming the District as an additional insured shall: Be an insurance policy from A.M. Best rated secure or better insurer, licensed in New York State. State that the organization s coverage shall be primary and non-contributory coverage for the District s Board, employees and volunteers. The District shall be listed as an additional insured by using endorsement CG 2026 or equivalent. A completed copy of the endorsement must be attached to the certificate of insurance. At the Districts request, the organization shall provide a copy of declaration page of the liability and umbrella policies with a list of endorsements and forms. If so requested, the organization will provide a copy of the policy endorsements and forms. The permittee agrees to indemnify the District for any applicable deductibles and self-insured retentions. II. The insurance producer must indicate whether or not they are an agent for the companies providing the coverage. III. Required Insurance: Commercial General Liability Insurance $1,000,000 per occurrence/ $2,000,000 aggregate, with coverage for athletic participants. IV. Permittee acknowledges that failure to obtain such insurance on behalf of the district constitutes a material breach of contract and subjects it to liability for damages, indemnification and all other legal remedies available to the District. The permittee is to provide the District with a certificate of insurance, evidencing the above requirements have been met, prior to the commencement of work or use of facilities. V. The District is a member/owner of the NY School Insurance Reciprocal (NYSIR). The user further acknowledges that the procurement of such insurance as required herein is intended to benefit not only the District but also NYSIR, as the District s insurer.
15. Prior to the start of the event, an announcement should be made to your group regarding emergency evacuation procedures. For example, pointing out posted procedures, directions for exiting, how to respond to a fire alarm, etc. 16. In the event of an accident, please notify the custodian on duty, or call the Facilities office the next morning (767-4940). 17. District AED locations: Administration Building- Front Lobby Daly Elementary School- Main Hallway by Entrance Daly Annex- On wall outside BOE Conference Room Guggenheim Elementary School- Main Entrance Lobby Sousa Elementary School- Main Entrance - bottom of stairs Manorhaven Elementary School- Main Entrance -- outside Main Office Salem Elementary School- 2nd Floor - Top of steps Weber Middle School (3)- Lower Lever - outside of Gym Main Floor - Next to Elevator Main Floor - Hallway of New Addition Schreiber High School (4)- Lower Level - Across from Elevator Lower Level - Outside Gym Main Level - Across from Main office by Staircase 2nd Floor- Across from Elevator FEES Rate Schedule attached CERTIFICATION I have received, read, and am familiar with Policy and Requisition # 1500, Public Use of School Facilities, and Policy #1520, Public Conduct on School Property, and agree that our organization will abide by them. Forty-eight hour notice of cancellation must be given if the group to which permission has been granted is unable to appear. Failure to do so will incur custodial expenses as scheduled. Permit will be cancelled when schools are closed for emergencies. The undersigned is over 21 years of age and has read this form and attached regulations and agrees to comply with them. He/she agrees to be responsible to the District for the use and care of the facilities. He/she, on behalf of (Name of Organization) does hereby covenant and agree to defend, indemnify and hold harmless the District from and against any and all liability, loss, damages, claims, or actions (including costs and attorney fees) for bodily injury and/or property damage, to the extent permissible by law, arising out of or in connection with the actual or proposed use of District s property, facilities and/or services by (Organization). Signature Title Print Name Address Date Permit Issued Port Washington Board of Education Signature of Director
Consecutive multi-day not-for-profit users, 3 days or more, will be eligible for a 3 hour season participant fee. deposit equal to 20% of the overall cost which will be paid in advance. As long as there is no minimum/maximum hourly rate. Yearlong lease holders will be further discounted 10%. district staff or district s vendor for stage lighting, sound, etc. damage, the 20% will be credited against the final facilities billing. All applicants must utilize r r c r j ( rrj JAMS rfting ihkrl ijeee 3c]1o1 ilnstrict jth. Ti F TitiilJ Q ci i:r 56. RATES FOR USE OF SCHOOL FACILITIES FOR 2013-20 14 Be it resolved that the following daily rates be established for use of school facilities by resident and non-resident organizations: *Any event for the predetennined duration of 3 hours or more must provide damage/security q at 11 Classrooms $50 $75 Gymnasium $70/per use $75 Athletic Fields $70/per use 0 Courtyard (not available) Parking Lots $50 0 Cafeteria $50 $75 Cafeteria w/ Kitchen All-Purpose Rooms $65 $75 our staff only $55 $75 Hourly Rate Weekend Hourly Rate Auditorium* $100 $75 Facility All Users Custodian provide rosters to the Facilities office in advance and pay a $1 0/per person/per Below are the hourly rates for use of school facilities by adult resident recreational and B. Residents Resident Recreational and Adult Resident not-for-profit groups Adult otherwise scheduled to be closed. minimum of a 4 hour rate, for any location that is requested to be opened, if rosters to the Facilities office. In addition a $75/hour custodial fee will apply, with a adult resident not-for-profit groups for 2013-2014 under Policy and Regulation location that is requested to be opened, if otherwise scheduled to be closed. A. Resident volunteer led youth groups: Will be charged participant fee of $10 per child /per season/per activity and provide 1500. A $75/hour custodial fee will apply, with a minimum of a 4 hour rate, for any In addition to fees of the rate schedule, all adult resident athletic groups must
Facility Facility Opening Custodial The rates for use of school facilities by for profit resident or non-resident groups are with building bathrooms $150 0 $75 Per Tennis Court $110 overall cost which will be paid in advance. As long as there is no damage, the 20% will be credited against the final facilities billing. All applicants must utilize district staff or districfs Auditorium* $200 $140 $75 Cafeteria w/ Kitchen our staff only $80 $210 $75 Gymnasium $110 $140 $75 Cafeteria $75 $140 $75 Classrooms $75 $70 $75 Athletic Fields $150 0 0 Athletic Fields Parking Lots $150 0 0 vendor for stage lighting, sound, etc. Competition including more than two teams is considered to not meet the 50% Port participation Board of Education Policy #1500 (see www.portnet.k12.ny.us) provides conceptual information as to the proper categorizing of groups such as AAPW, HSAIPTAs, HEARTS, PWEF, etc. D. Exempt Organizations: All-Purpose Rooms $75 $140 $75 necessary to be considered a resident activity. *Any event for the predetermined duration of 3 hours or more must deposit equal to 20% of the jjpyrate iijcleanig t{l Rate as follows: C. ForProfpand!orjresjçt: FAX 51 6-7674949 5$-767494F T KATHLEEN A. MOENEY. EFD, 5167675OO5 Jrt on Free School District nn ij (vh ikic