SCHOOL FACILITY USE PERMIT REQUEST
LAKE SUPERIOR SCHOOL DISTRICT NO. 381
To submit this facility request form please email, mail, fax or drop off.
Today’s date: __________
No phone requests are taken, however it is advisable to check with the
Community Education Office to ensure that facility is available for the desired date.
Two Harbors High School (Door 17) - 1640 Hwy 2, Two Harbors, MN 55616
Phone: 218-834-8201, ext. 8230 Fax: 219-834-8263
Email: solson4@isd381.k12.mn.us
William Kelley High School 137 Banks Blvd, Silver Bay, MN 55614
Phone: 218-226-4437, ext 8137 FAX 218-226-4860
Email: marilynJ@isd381.k12.mn.us
This form must be submitted to the Community Education Director
at least 7 working days prior to the rental date. Submission of this form is request only (not approval).
Organization Name _________________________________________________________________
Client Type:
_____Resident/Organization* _____Nonresident/Organization*
_____School Sponsored/Approved Activity
Address ________________________________________________________________
City, State, ZIP ___________________________________________________________
____________PIN NUMBER (CE office will assign this pin number for you)
Primary Contact Person(s) First Name________________________________________________________
Last Name ______________________________________________ Title _____________________________
Address ____________________________________ City State ZIP__________________________________
(if different from organization information)
Office Phone_________________________
Cell Phone ________________________
Home Phone _________________________
Office FAX _______________________
Email ________________________________________________ I do not want my contract emailed _____
(facility contracts will be emailed unless requested otherwise)
Name & Phone number of person supervising event (if different from primary contact above)
Name ____________________________________ Phone ______________________________________
Type of Activity/Event ____________________________________________________________________
Date(s) requested ________________________________________________________________________
Start Time __________________ Ending Time __________________ Set Up Time _________________
Tear Down _____________________ Will vacate building by ___________
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SCHOOL FACILITY USE PERMIT REQUEST
LAKE SUPERIOR SCHOOL DISTRICT NO. 381
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School To Be Used
Minnehaha _____ Two Harbors High School ______ William Kelley ______
Location(s)/Rooms Requested ___________________________________________________________
Equipment, etc. requested (please indicate amount): TV/VCR_______ Chairs ______ Tables _______
Overhead Projector _______ Screen _______ Microphone _______ Podium ________
Other : _____________________________________________________________________________
Custodial Supervision Required ______________
(outside of normal working hours or if the event would requires additional staffing beyond normal schedules)
Kitchen Supervision Required _______________ (The kitchen is not available without School Food Service
staff present)
Lighting Tech Required _______
(for Auditorium use)
Life Guards Required _______
(for pool use)
Special Setup Notes:
__________________________________________________________________________________________
Attendance Anticipated _______
I request use of the district facilities as noted in this permit request. I have the authority to legally bind this organization and
hereby obligate the organization to provide liability insurance coverage in the amount of at least $500,000 and to indemnify
the school district and hold it harmless from any liability arising from our use of the school district property. I understand the
district needs to be named on the certificate as additionally insured. Requests are not valid until copy of insurance certificate
is received and on file at the Community Education office. I understand buildings and property are tobacco and alcohol free.
The organization agrees to comply with all State and federal non-discrimination laws. The organization will be responsible for
any and all damages to the school district property arising from our use. The organization has familiarized itself with the
Facilities Use Policy # 902 of the District and agrees to comply with all conditions of that policy. The organization accepts that
the school district may have to preempt our scheduled use of district facilities in which case we understand the district will
give as much advance notice as possible and that any money we have paid for use of the facilities will be refunded.
________________________________________________________
(Signature of person obtaining permit)
______________________
(Date)
-------------------------------------------------------------------------------------------------------------------------------------Office Use Only:
Key Card Number _______________ Key Number ________ Signature of person assuming key responsibility:
________________________________________________________________________________________:
Approved: _________________________________ _________________________________________
Building Principal
Community Education Director
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