General Use Application

Person or Group Requesting Use: *

Address *

Address

City

State/Province

Zip/Postal

Home Phone: *

Work Phone: *

Cell Phone:

Email Address: *

Sponsoring Organization:

Designated Agent or Applicant: *

Date Needed: *

Enter ACTUAL EVENT TIME *

Start Time: (Include SETUP Time Needed) *

End Time: (Include CLEANUP Time Needed) *

Recurring:

Enter recurring cycle if event is recurring, examples:
Every __ day(s)
Every Weekday
Every ___ week(s) on _____________ (day of week)
Day ____ of every ____ month(s)
The ____ (which) ______ (day) of every ____ months(s)
Recur every _____ year(s) on ______ (month) _______ (day)
Recur every _____ year(s) on the ______ (which) __________ (day) of _______ (month)

Range of Recurrence:

If Recurring, enter range, examples:
Start ________
No end date
End after _____ occurrences
End by __________________

Rooms Needed and Equipment to be used:

Number of Classrooms

Instructional Equipment:

Expected Number of Attendees:

Expected Number of Attendees: *

Names (if any) who are members of MLC

Describe the Purpose of Event: *

Person or Group Responsible:

Name of person or group responsible for care, use, and damage to facilities and equipment used.

Name of Person or Group: *

Address *

Address

City

State/Province

Zip/Postal

Home Phone: *

Work Phone:

Cell Phone:

Email Address *

Insurance Information:

Insurance Information when required:

Name of Liability Insurance Carrier:

Amount of Liability Insurance Coverage:

Damage Deposit of $50

Building Use Fee (see fee schedule)

On Behalf of the Applicant, I Certify that: *

I have read and am familiar with, and will follow the Policy and Procedures for Building Use at Macedonia Lutheran Church.

On Behalf of the Applicant, I Certify that: *

The applicant will abide by the Macedonia Child Protection Policy

On Behalf of the Applicant, I Certify that: *

Upon approval and prior to the event, the applicant will post the appropriate fee for the use of the MLC facilities.

On Behalf of the Applicant, I Certify that: *

The applicant will indemnify and hold Macedonia Lutheran Church of Burlington, NC harmless from any and all claims, damages, liabilities, or judgments, including costs and attorney fees that may arise as a result of the applicant's use of the MLC facilities.

Name: *

Signature *

By checking this box you are providing your electronic signature.

Title:

Date *

For Office Use Only:

Date Approved:

Date Denied:

Comments:

Date Applicant Informed of Decision:

Date Use Fee Paid:

Date Custodian Informed of Decision:

Date Damage Deposit Received:

Date Damage Deposit Returned:

Damage Deposit Amount:

Date Use Fee Received:

Use Fee Amount:

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