FACILITIES and EQUIPMENT USE FORM
(540) 967-1364
Individual/Organization Name:
_____________________________________ Date of Application:
_____________
Contact Name:
_____________________________________________ Phone Number:
_____________________
Contact Address:
_______________________________________________________________________________
Check which item best
describes your group:
_______ Non-Profit
Organization ______
Religious Group
_______ Member of
_______ Other:
____________________________________________
Facility and/or Equipment Requested:
_________________________________________
Date(s) Requested: ______________________
Time Requested: _____________ to _____________
Number of people involved: ___________
Brief explanation of your request:
_________________________________________________________________
_____________________________________________________________________________________________
List any equipment or materials that
will be brought onto the church grounds: _______________________________
_____________________________________________________________________________________________
Please return forms, fees and
other needed information to the Church Office at your earliest convenience as
your reservation can only be confirmed upon receipt of the above.
We agree to comply with the rules
and regulations of the Louisa Baptist Church, as outlined in the Policy for Use
of
Facilities.
________________________________________________
_____________
Signature (must be same as on
Policy for use of Facilities)
Date
________________________________________________
_____________
Signature of Approval from
Property and Use Focus Group Date
Facilities Fee Required:
____________
Audio/Visual Attendant Fee:
____________
Kitchen Attendant Fee:
____________
Facility Attendant Fee:
____________
Total Fees Required:
____________
An additional deposit of $200.00 is required and will be refunded if property is left in the original state and clean.