School District of Holmen - Elementary Facility Use Request Form
Facility requesters are required to read and be responsible for the guidelines noted on this form. Providing
information on this form, or communicating by any other means, does not guarantee the request is approved.
Approved request forms will be dated and signed by the Holmen School District Facility Coordinator.
Contact Person
Phone (work)
(home)
City
State
Email Address
Address
Street
Event Title
Zip
# of Participants
Description of the Activity
Event Start Date & Day
Event End Date & Day
If multiple dates, list ALL dates
Event Start Time
A.M.
P.M.
Event End Time
A.M.
P.M.
***If you need to setup prior to the event start time indicate the setup start time here.
Building and facility areas. Please check the area(s) of the building you are requesting.
Evergreen Elementary
Old Gym
New Gym
Softball Field
Kitchen
Art Room
Music Room
Computer Lab
LMC
Bathrooms
Classroom/s
Viking Elementary
Old Gym
New Gym
Field #1
Field #2
Field #3
Field #4 (Var)
Soccer Field
Football Field
Tennis Courts
Shelter
Kitchen
Cafeteria
Classroom/s
Conference Room
Window Lounge
2/3 Open Area
4/5 Open Area
Art Room
Music Room
Computer Lab
LMC
Bathrooms
Prairie View Elementary
Gym
Ball Field
Stage
Cafeteria
Kitchen
Art Room
Music Room
Computer Lab
LMC
Bathrooms
Sand Lake Elementary
Classroom/s
Gym
Ball Field
Stage
Cafeteria
Kitchen
Art Room
Music Room
Computer Lab
LMC
Bathrooms
Discovery Cntr K-1
Discovery Cntr 2-3
Discovery Cntr 4-5
Family Learning Center
Gym
Playground
Bathrooms
Classroom/s
Discovery Cntr K-1
Discovery Cntr 2-3
Discovery Cntr 4-5
Equipment Needs
Classroom/s
Screen
Podium
TV
DVD
VCR
Serving Table
Overhead
Projector
Microphone
Microphone Stand
Other
Please list any specific setup requests:
~Fees noted below are an estimate based on the information provided above. The actual costs will be charged after the event
has concluded and all accountings are made. Please see the School Board Policy for requirements, and liabilities.
Estimated Costs:
AV/IT Staff Fee
$
Approved By (Facility Coordinator)
Activities Office Use Only
Facility Fee
$
Custodial Fee
$
Food Service Fee
Equipment Fee
$
$
Date