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r.r - NOV 2 LINCOLN UNIFIED SCHOOL, DIST NMEWAL HEALTH -- 2010 West Swain )toad, Stockton, CA "rS �MSG OOF FAC��l��'�C O FOOR�TIIEIICES APPLICATION FOR USE OR RENTAL OF SCHOOL FACILITIES FACILITY DATES REQUESTED: DAY(S)OF THE WEEK: HOURS OF USE:from DREVIBER 4, 1991 EbWd&ft Wednesday (circle days)M Tu w F sa s- 6.�I P pm'D 9:00 ly am NAME OF ORGANIZATION: PURPOSE OF MEETING: TH PIMLICTH EXXON - Public Mgeting NAMF,OF RESPONSIBLE PERSON IN CHARGE DAYTIME PHONE NUMBER. Box 2009, (445 North San Joaquin St) GIT tockton, CA ZIP:95201 EXPECTED ATTENOANGE AbMISSI3N CHARGE,COLLECTION OR DONATION FROM PARTICIPANTS PROCEEDSTO BE USED FOR: 120 (chock ane) O will he made IW wi II=bo made n/a SCHOOL OR SITE BEING REQUESTED: Mable Barron School TYPE OF FACILITY BEING REQUESTED: (check one or more) ❑ Classrooms (under 50 capacity) ❑ Lincoln High School Stadium ❑ Classrooms (aver 50 capacity) ❑ Lincoln High P.A. or Scoreboard XXX Multi-Use Room ❑ Lincoln High Stadium Lights ❑ Sierra Pacific Gymnasium ❑ Lincoln High Swimming Pool ❑ Lincoln High School Gymnasium ❑ Kitchen(circle equipment needed)refrigerator stove ❑ Lincoln High Performing Arts ❑ Other SETUP INSTRUCTIONS: FEES (use of facility fees must be paid in advance}: Traditional lecture format with long tables Fec{Itty Use Fel $ in front for program organizers, podium for g speaker, screen for slide presentation, se up for 120 members of the public. Table Custodian sl X—haurs.a near entrance for sign-in sheets and hand- Kitchen Supervisor z X_hnurs.S out materials. Microphone in front. TOTAL 5 INSURANCE= REQUIREMENTS: INSURANCE CERTIFICATE providing evidence of$1,000,000 combined single limits. The following statement must he on the certllicale: LINCOLN UNIFIED SCHOOL DISTRICT IS NAMED AN ADDITIONAL PARTY INSURED. ADDITIONAL INSURED ENDORSEMENT will put Lincoln Unified School District directly on your policy only for the length of time the facility Is being used by your organization. Your insurance agent can provide the required certificate and endorsement. AFFIDAVIT IN ACCORDANCE WITH EDUCATION CODE SECTION 40057 The undersigned states that,to the best of hitil knowledge,the school property In,use of whit app hcalion,s hereby made,will not be used for the commission of any act rounded to further any programor movement the purpose of which is to accomphsh the overthrow of flit liovernment of the honed State,,by force,violence or other unlawful moons That this organization on whose behalf holshe is making apphrnaon for use of school property,doe r�or Io Il k...l of hwher 4.nowladgo,advocatr the overthrow of the Government of the United States or of the State of Gil by fur,e, aol.n or ulhar un lnwl cel mnatrs,an, to It-1n9f of I—hof knowledg H,iI tr,nut a cornmunrataction orgam7ahon Or communili boot organization required by law to ha ray is le r ed with Ih•,Anornuy General o Il I luomr t.s.;tri. I hi,.t„—n—i is made under the penalties of perjury rlbi Il HAHIAL I S',A1,141-Fill App!a ants hereby agree to hold the Lincoln Ilurli ci+ol Disl lot.Its Gevernmg Board,the mdividuala ntenibert:no,re 1,,end all di,,tncl ollu ars nn,mts and onrpluyo..s Iree and harmless Irom any loss,damage,Ilabdity, st or xpenasl that may ante during or be caused In any way by such uucupancy of sc ho pruperry 7h auohcard agroos to reimburse the school dishct for any de a 1s echo 1 prop ty oce'asslonad by or growing out of use herein requested AUTHORIZED$I TORE O APPLICA DATE-- Z ATE- School Panup.,!Approval OsloT /�� ■/r 11 .i„n.s OII.cr Approval --gyp/-- _171i / ' I / 1, l .._. LINCOLN UNIFIED SCHOOL DISTRICT IS A NO SMOKING - NO TOBACCO PRODUCT DISTRICT. BOARD POLICY 3513 Pu v Business Off'. Conary School Golden rod-Culiodren