Facilities Request Form Date of Submission MM DD YYYY Activity/Event name: Person/Group requesting use: 501(c)(3) Welfare Tax Exemption Statement and Certificate of Liability Insurance will be required. Arrival date: MM DD YYYY Arrival time: Hour Minute Second AM PM Departure Date MM DD YYYY Departure Time Hour Minute Second AM PM Is this a recurring event? Yes No Rooms(s) requsted: Dormitory Bunk Bed Cole or Fredrick Bedroom Kitchen Only Dining Room Only Gymnasium Chapel Waller Conference Room Masonic Music Room Phoenix Conference Room Set-up time (#number of minutes) needed: Clean-up (#number of minutes) needed: Recurring event? Yes No ROOM SETUP AND CLEAN UP:(Please Select) I will be responsible for room setup and clean up. I agree to leave room(s) and equipment in original condition after use. Do you plan to bring extra equipment for your setup? Yes No If Yes, please list: I request help with room setup or obtaining items not found in the room. I understand that this will require a special charge. Please describe your request: FOOD SERVICE: (Check if applicable) Note: If a member of your party does not have Serve Safe Certification or equivalent, you will be required to meet with the site manager upon arrival before kitchen use. I plan to use the kitchen for food preparation. I agree to keep it clean and abide by Serve Safe guidelines and regulations. The following person has Serve Safe Certification or will meet with the site manager upon arrive: First Name Last Name I request help with meal preparation. I understand that Waller Center does not have kitchen staff, and this will require a special charge. Please describe your request: PROGRAMS: (Check if applicable): If yes, we will follow up with more information No I AGREE TO BE RESPONSIBLE FOR: (Must check to indicate that you have read and understand) NOTE: The Waller Center reserves the right to move your event to another time and/or space if unforeseen events make it necessary to do so. Using only the rooms and equipment that have been requested and confirmed. Not permitting smoking in any room. THE USE OF ALCOHOL AND ANY ILLEGAL SUBSTANCE IS PROHIBITED ON CAMPUS. Closing all windows, turning off lights and locking all doors after use. Returning assigned key(s) promptly after the event. First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email Title Phone (###) ### #### Office Thank you!
