LAS CRUCES PUBLIC SCHOOLS                                                              Building Use Form
                                                                                             Date Submitted:

This form is to be used when requesting the use of a school building. Make sure all sections are complete before submitting. Please
hand carry or send through the school mail to Operations Department, faxes will only be accepted for school sponsored events.

Date of Use:                  School:                   Room/Location:

Times: Open Building-                        am/pm           Event-               am/pm           Close Building-                  am/pm
Other dates/times (if more than one):
Special Requests: If additional space is needed, submit another page.
Principal’s Signature: _______________________________________                                  Date_________________
Will admission be charged or collections solicited? Yes                            No
Are you selling food? Yes                _ No         (If yes, attach food permit and MOU

Will Kitchen Facilities be used? Yes                    No          If yes, time needed:             to
(If kitchen facilities are requested, a food services worker is required)   Set Fee - $25.00 per hour Food Service Worker

Custodian needed? Yes                   No          If yes, # of custodians needed
Set Fee- $21.00 per hour for each custodial worker needed

Total Fees Due                 (Attach a Money Order made Payable to LCPS)
Liability insurance needed?                       Yes         No
(If organization is not affiliated with the school district, organization must obtain the school district as an additional
insurance holder and attach to form.)
Applicant Information
This application is made subject to the General Regulations for the use of school buildings. The undersigned agrees that these rules shall be strictly
observed and accepts entire responsibility for the enforcement of these rules, and agrees to protect the premises and indemnify the School district for
any damage due to occupying the building covered by this permit. It is understood and agreed to by the applicant that this permit may be revoked or
cancelled at any time with or without cause and that in the event of such revocation or cancellation, there shall be no claim by the undersigned for right to
damages or reimbursement on account of any loss, damage, or expense whatsoever. The undersigned further agrees to protect, indemnify and save
harmless the School District and its officers and employees from any and all claims, liabilities, damages, or rights of action directly or indirectly growing
out of the use of the premised covered by this application.

Name of Organization:
Contact Person:
Mailing Address:                        City/State/Zip:
Phone Number:                          Fax Number:             E-mail

Representative’s Printed Name:
Representative’s Signature: __________________________                               Date:


Food Permit Attached             Nutritional Guidelines Compliance MOU Attached                       Liability Policy Attached                  Other

           Approved                      Disapproved                        Need to Resubmit- (documentation not included)
Coordinator of Custodial Services Signature: ___________________________________                    Date: __________________

LCPS FORM # 84                                               Revised 10/08                    Original: Associate Superintendent of Operations
Routing: School / Operations / PPD

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