APPLICATION AND AGREEMENT FOR USE OF FACILITIES
Name of Organization:
Officially Represented by:
Name and Title (must be officer or have written permission)
Facility Requested: Locke 1 ( ) Locke 2 ( ) Board Room ( ) Locke 1 & 2 ( )
Locke 2 & Board Rm ( ) Locke Auditorium ( ) Staff Lounge (Kitchen) ( ) Computer Lab II ( ) Kingston Room ( ) Alpine Room ( ) Emerson Room ( ) Justice Room ( )
Island Room ( ) Bungalow Room ( ) Burwood 1 ( ) Burwood 2 ( )
Burwood Auditorium ( ) Greenwood 1 ( ) Greenwood 2 ( ) Greenwood 3 ( ) Greenwood 4 ( ) Greenwood 5 ( ) Chartville 1 ( ) Chartville 2 ( ) Chartville Auditorium ( ) Harmony Grove Lab ( ) Summer Home Rm ( ) Salem Room ( ) River School Room ( ) Everett Room ( ) Castle Room ( ) Bellota Room ( ) Fairchild Room ( ) Brunswick Room ( ) Four Tree Room ( ) Lafayette Room ( ) Atlanta Room ( ) Open Forum ( ) Delphi Room ( ) Weber Room (lab) ( ) Independent Rm(lab) ( ) Enterprise Rm (lab) ( ) Burbank Rm (lab) ( ) Bixler Room ( ) Emerson Room ( ) Fair Oaks Forum ( ) Garden Room ( ) Moore Room ( ) Mossdale Room ( ) Schneider Room ( ) Stockton High Rm ( ) Telegraph Room ( ) Wildwood Room ( ) Ropes Course ( ) Durham Ferry Park ( ) Venture Auditorium ( ) Venture Gym ( ) Venture Kitchen ( ) Venture Common Area ( ) Venture Library ( ) Venture Locker Rms ( ) Non-Profit # ( ) Commercial ( ) Puma Nation Gym ( ) Electric Vehicle Charging Station ( )
Set Up: U-Shape ( ) Square ( ) Classroom ( ) Chairs Only ( )
Equipment: Food Tables ( ) Presenter Table ( ) Overhead Projector ( ) Screen ( )
Easel ( ) TV/VCR ( ) Podium ( ) Stage ( )
AV Cable ( ) Lapel Microphone ( ) Hand-held Microphone ( )
Purpose or Type of Use:
Will be used for: Monthly ( ) One Time ( ) Other ( )
Date(s) requested: Day(s) of the week (circle) M Tu W Th F Sa Su
Hours: From: To:
Expected Number of attendance:
Proceeds to be used for:
SAN JOAQUIN COUNTY OFFICE OF EDUCATION REQUIRES A CERTIFICATE OF INSURANCE DOCUMENT FROM YOUR INSURANCE COMPANY BEFORE YOUR USE OF FACILITIES REQUEST CAN BE APPROVED. Insurance certificate providing evidence of bodily injury insurance with limits of not less than $300,000 each person, $1,000,000 each accident, and $100,000 of property damage. The following statement must be on the certificate: SAN JOAQUIN COUNTY OFFICE OF EDUCATION IS NAMED AN ADDITIONAL PARTY INSURED. Additional insured endorsement will put San Joaquin County Office of Education directly on your policy only for the length of time the facility is being used by your organization. Your insurance agent can provide the required certificate and endorsement. Insurance not required for Electric Vehicle Charging Station use.
AFFIDAVIT IN ACCORDANCE WITH EDUCATION CODE § 40057:
The undersigned states that, to the best of his/her knowledge, the property for use of which application is hereby made, will not be used for the commission of any act intended to further any program or movement, the purpose of which is to accomplish the overthrow of the Government of the United Stated by force, violence or other unlawful means. That this organization on whose behalf he/she is making application for use of property, does not, to the best of his/her knowledge, advocate the overthrow of the Government of the United States or the State of California by force, violence, or other unlawful means, and that to the best of his/her knowledge it is not a communist-action organization or communist-front organization required by law to be registered with the Attorney General of the United States. This statement is made under the penalties of perjury.
AUTHORIZED SIGNATURE OF APPLICANT: DATE:
APPROVED: DATE: REASON IF NOT APPROVED:
HOLD HARMLESS & INDEMNIFICATION AGREEMENT
Notwithstanding any insurance coverage which may be in effect, and in addition to any additional undertakings referred to herein, Applicant agrees at all times to protect, indemnify, and hold the San Joaquin County Office of Education, its Board, officers, members, representatives, agents, guests, invitees, and/or employees free and harmless, and to provide legal defense, from any and all liabilities, claims, losses, judgments, damage, demands or expenses resulting from the Applicant’s use or occupancy of the San Joaquin County Office of Education’s facilities and/or the active or passive negligence of the Applicant or the San Joaquin County Office of Education, its Board, officers, members, representatives, agents, guests, invitees, and/or employees, specifically including, without limitation, any liability, claim, loss, judgment, damage, demand, or expense, arising by reason of:
(1) the loss or damage to any of the San Joaquin County Office of Education’s facilities including any building, structure, or improvement thereon
, or any equipment to be used therein;
(2) the injury to or death of any person including, but not limited to, the officers
, members, representatives, agents, guests, invitees, and/or employees of the Applicant or of the San Joaquin County Office of Education; or,
(3) damage to any property arising from the use
, possession, selection, delivery, return, condition or operation of the San Joaquin County Office of Education’s facilities.
Applicant further agrees to reimburse the San Joaquin County Office of Education for all liabilities
, claims, losses, judgment, damage, demands, expenses, fines, penalties, including reasonable attorneys’ fees imposed or incurred by the San Joaquin County Office of Education because of the Applicant’s use or occupancy of the San Joaquin County Office of Education’s facilities and/or active or passive negligence of the Applicant or of the San Joaquin County Office of Education, its Board, officers, members, representatives, agents, guests, invitees, and/or employees.
THIS AGREEMENT SUPERSEDES ANY OTHER HOLD HARMLESS AND INDEMNIFICATION AGREEMENT RELATIVE TO USE OF SAN JOAQUIN COUNTY OFFICE OF EDUCATION FACILITIES.
OFFICE USE ONLY:
FEES: As per Facilities Fee Schedule
Facility use hours @ $ = $ Insurance Received: Yes ( ) No ( ) N/A ( )
Facility use hours @ $ = $ Invoice:
Facility use hours @ $ = $
( ) Custodian hours @ $ = $
Repair or damage to facilities: = $