General Use Application General Use Application Form and Agreement For use of Macedonia Lutheran Church Building and Facilities NOTE: You are NOT guaranteed use of facilities until the church secretary has confirmed it! General Use Application and Agreement Person or Group Requesting Use: * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Home Phone: * Work Phone: * Cell Phone: Email Address: * Sponsoring Organization: Designated Agent or Applicant: * Date Needed: * Enter ACTUAL EVENT TIME * 121234567891011 : 0030 AMPM Start Time: (Include SETUP Time Needed) * 121234567891011 : 0030 AMPM End Time: (Include CLEANUP Time Needed) * 121234567891011 : 0030 AMPM Recurring: 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: Select Rooms and Equipment: Luther Hall Kitchen Sanctuary Nursery Classrooms Organ Piano Instructional Equipment OtherOther 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 Address Address City City State/Province State/Province Zip/Postal 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: CAPTCHA If you are human, leave this field blank.