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HomeMy WebLinkAboutUkiah Unified School District 2026-06-10COU No. 2526-210r 04/28/2026 Page 1 of 2 UKIAH UNIFIED SCHOOL DISTRICT APPLICATION AND AGREEMENT FOR USE OF FACILITIES District/Certificate Holder: Applicant: Ukiah Unified School District Address: 511 South Orchard Avenue, Ukiah CA 95482 Company/Organization: Non-profit organization? __Yes __No Phone: (707)-472-5012 Email: kristinakeene@uusd.net Requestor’s Name: (Must be an officer or authorized representative of company/organization) Address: Phone: Email: Facilities Requested. School Site: Facility/Room Requested: Please indicate exact date(s) and time(s) requested. One-time Use Daily Use Weekly Use Monthly Use Month Date(s) Year Day of Week Time (from/to) Expected Attendance % of District Students Will a donation, fee or charge be collected from participants? Yes No If yes, how will the proceeds be used? _________________________________________________ Is the use non-exclusive and open to the public? ____ Yes ____ No 1.Indemnification: To the fullest extent permitted by law Applicant shall hold harmless, defend and indemnify the District, its governing board, officers, agents and employees, from and against any liability, claim, action, cost, damage or loss, including reasonable costs and attorneys’ fees, for injury, including death, to any person or damage to any property arising out of the activities of Applicant or its agents, officers, employees, invitees or guests in or about the Facilities, whether or not there is concurrent passive or active negligence on the part of District, but excluding liability due to the sole negligence or willful misconduct of District. This obligation shall continue beyond the term of this Agreement as to any act or omission that occurred during or under this Agreement. This indemnification obligation is not limited in any way by any limitation on the amount or type of damages or compensation payable to Applicant or its employees or agents under workers’ compensation acts, disability benefit acts, or other employee benefit acts. 2.Insurance: Attach a Certificate of Insurance with Additional Insured Endorsements specified in the Insurance Required of Applicant Section clearly evidencing all coverage, limits, and endorsements required. Said certificates shall be submitted prior to the execution of this Agreement. This policy shall not be canceled or materially changed without first giving thirty (30) days prior written notice to District. Upon District’s written request, certified copies of insurance policies shall be submitted within thirty (30) days of the District’s request. Applicant’s indemnity and other obligations shall not be limited by the foregoing insurance requirements. If applicant, for any reason, fails to maintain insurance coverage as required, the right to use the Facilities shall be deemed revoked. 3.Fees: Applicant understands that direct costs / fair rental value fees will be assessed in accordance with the District’s policies and regulations. An application fee and % deposit on estimated use fees are due upon submittal of this Application and Agreement for Use of Facilities. Applicant agrees Event /Program: UUSD/ City of Ukiah Summer Safari, Swim Lessons If this request is by the City of Ukiah, no other information is needed; skip to the signature section and sign. Ukiah High School Pool, Pool locker room, adjacent weight room, track & field, basketball courts blacktop, track bathrooms, grassy area between pool and cafeteria, Tri/ Tri seating Cafeteria for excessive heat days June 8-August 16 2026 Mon- Fri 7am - 8pm 100-150 99% Jessika Ramos Daniel Spence 411 West Clay Street (707)272-2257 cborgna@cityofukiah.com Page 2 of 2 to remit payment in full within thirty (30) days after District’s issuance of an invoice. 4.Compliance with District Policies and Regulations: Applicant shall comply with District policies and regulations concerning including, but not limited to, the prohibitions against unlawful discrimination and use of tobacco and alcohol on District property. Applicant shall inform its staff and event/program participants that tobacco and alcohol use are prohibited and shall strictly enforce the policy. Applicant shall not make any modifications or alterations to the facilities without the advanced, specific, written authorization of District. 5.Supervision: Applicant shall be responsible for providing adequate personnel to supervise all persons who enter the Facilities during Applicant’s authorized use periods. 6.Applicant is responsible to repair or replace anything damaged during their use. The District will inspect facility after use to determine damages, if any. Insurance Required of Applicant As evidenced by Certificate of Liability Insurance, Additional Insured Endorsement and other Amendatory Endorsements: Certificate Holder: Ukiah Unified School District 511 South Orchard Avenue Ukiah, CA 95482 Commercial General Liability or Personal Liability on an occurrence form with a minimum limit of $1,000,000 each occurrence / $2,000,000 general aggregate for all groups except: a)Seasonal Sports/Recreation Leagues, Sober Grad Organizations, or Private Events with 500+ attendees: Minimum limit of $2,000,000 each occurrence / $2,000,000 general aggregate. b)Year Round Sports/Recreation Leagues: Minimum limit of $5,000,000 each occurrence / $5,000,000 general aggregate c)Use of Swimming Pool Minimum limit of $6,000,000 each occurrence / $6,000,000 general aggregate. Additional Insured Endorsement: This is a separate form attached to the certificate. The endorsement must name Ukiah Unified School District, it’s elected or appointed officials, employees, agents and volunteers as Additional Insured (or Additional Covered Party) under the general liability policy. Forms CG 2026 or CG 2011 or equivalent required. For purposes of the CG 2011 only, this Agreement shall be deemed to be a lease. Blanket Additional Insured forms are acceptable when accompanied with an approved Facility Use Agreement. Evidence of Primary Insurance (either by endorsement or the actual page(s) of the policy typically found in the “Other Insurance” section of policy): Applicants insurance shall be primary insurance as respects to Ukiah Unified School District, it’s elected or appointed officials, employees, agents and volunteers. Any insurance or self-insurance maintained by Ukiah Unified School District, its elected or appointed officials, employees, agents and volunteers shall be excess and shall not contribute with it. The individual signing below on behalf of Applicant warrants that he/she has read the foregoing terms and conditions, that he/she is authorized to execute this document, and that this document constitutes a legally binding obligation of the individual/organization which he/she represents. Date:3/5/2026 Applicant Signature: Applicant Address________________________________ Telephone (_____)__________________________ For Office Use Only Approved / Denied By: Date: Site Administrator Approved / Denied By: Date: Business Office Facility Available: Yes No Estimated Fees: Application Fee: $25.00 (non-refundable); Deposit: (applies toward fees); Date Paid: , 20__ District Cost: _______ Fair Rental Value: ________ Free: Labor Charge: Yes No School Employee Support Required for this Rental: Yes No Insurance Certificate Checklist: Limits Adequate Additional Insured Endorsement Primary Wording Provided 411 West Clay Street 707 272-2257 Page 1 of 2 UKIAH UNIFIED SCHOOL DISTRICT APPLICATION AND AGREEMENT FOR USE OF FACILITIES District/Certificate Holder: Applicant: Ukiah Unified School District Address: 511 South Orchard Avenue, Ukiah CA 95482 Company/Organization: Non-profit organization? __Yes __No Phone: (707)-472-501 Email: NULVWLQDNHHQH@uXVd.net Requestor’s Name: (Must be an officer or authorized representative of company/organization) Address: Phone: Email: Facilities Requested. School Site: Facility/Room Requested: Please indicate exact date(s) and time(s) requested. One-time Use Daily Use Weekly Use Monthly Use Month Date(s) Year Day of Week Time (from/to) Expected Attendance % of District Students Event /Program: Will a donation, fee or charge be collected from participants? Yes No If yes, how will the proceeds be used? _________________________________________________ Is the use non-exclusive and open to the public? ____ Yes ____ No 1.Indemnification: To the fullest extent permitted by law Applicant shall hold harmless, defend and indemnify the District, its governing board, officers, agents and employees, from and against any liability, claim, action, cost, damage or loss, including reasonable costs and attorneys’ fees, for injury, including death, to any person or damage to any property arising out of the activities of Applicant or its agents, officers, employees, invitees or guests in or about the Facilities, whether or not there is concurrent passive or active negligence on the part of District, but excluding liability due to the sole negligence or willful misconduct of District. This obligation shall continue beyond the term of this Agreement as to any act or omission that occurred during or under this Agreement. This indemnification obligation is not limited in any way by any limitation on the amount or type of damages or compensation payable to Applicant or its employees or agents under workers’ compensation acts, disability benefit acts, or other employee benefit acts. 2.Insurance: Attach a Certificate of Insurance with Additional Insured Endorsements specified in the Insurance Required of Applicant Section clearly evidencing all coverage, limits, and endorsements required. Said certificates shall be submitted prior to the execution of this Agreement. This policy shall not be canceled or materially changed without first giving thirty (30) days prior written notice to District. Upon District’s written request, certified copies of insurance policies shall be submitted within thirty (30) days of the District’s request. Applicant’s indemnity and other obligations shall not be limited by the foregoing insurance requirements. If applicant, for any reason, fails to maintain insurance coverage as required, the right to use the Facilities shall be deemed revoked. 3.Fees: Applicant understands that direct costs / fair rental value fees will be assessed in accordance with the District’s policies and regulations. An application fee and % deposit on estimated use fees are due upon submittal of this Application and Agreement for Use of Facilities. Applicant agrees ,IWKLVUHTXHVWLVE\WKH&LW\RI8NLDKQRRWKHULQIRUPDWLRQLVQHHGHGVNLSWRWKHVLJQDWXUHVHFWLRQDQGVLJQ City of Ukiah - Day Camp City of Ukiah 411 W. Clay St., Ukiah, CA Frank Zeek Elementary School Cafeteria, blacktop areas, all playgrounds and fields, two kinder rooms, rooms 3n, 20-24, and emergency use room in case needed 6/9/26 Tuesday TBD (Supply Move-In) 6/10/26-7/16/26 Monday-Friday 11am-6pm 400 100 7/17/26 Friday 9am-3pm (Supply Move Out) UUSD/City of Ukiah Summer School Safari ✔ Cassandra Borgna 707-272-2257 cborgna@cityofukiah.com ✔ Page 2 of 2 to remit payment in full within thirty (30) days after District’s issuance of an invoice. 4.Compliance with District Policies and Regulations: Applicant shall comply with District policies and regulations concerning including, but not limited to, the prohibitions against unlawful discrimination and use of tobacco and alcohol on District property. Applicant shall inform its staff and event/program participants that tobacco and alcohol use are prohibited and shall strictly enforce the policy. Applicant shall not make any modifications or alterations to the facilities without the advanced, specific, written authorization of District. 5.Supervision: Applicant shall be responsible for providing adequate personnel to supervise all persons who enter the Facilities during Applicant’s authorized use periods. 6.Applicant is responsible to repair or replace anything damaged during their use. The District will inspect facility after use to determine damages, if any. Insurance Required of Applicant As evidenced by Certificate of Liability Insurance, Additional Insured Endorsement and other Amendatory Endorsements: Certificate Holder: Ukiah Unified School District 511 South Orchard Avenue Ukiah, CA 95482 Commercial General Liability or Personal Liability on an occurrence form with a minimum limit of $1,000,000 each occurrence / $2,000,000 general aggregate for all groups except: a)Seasonal Sports/Recreation Leagues, Sober Grad Organizations, or Private Events with 500+ attendees: Minimum limit of $2,000,000 each occurrence / $2,000,000 general aggregate. b)Year Round Sports/Recreation Leagues: Minimum limit of $5,000,000 each occurrence / $5,000,000 general aggregate c)Use of Swimming Pool Minimum limit of $6,000,000 each occurrence / $6,000,000 general aggregate. Additional Insured Endorsement: This is a separate form attached to the certificate. The endorsement must name Ukiah Unified School District, it’s elected or appointed officials, employees, agents and volunteers as Additional Insured (or Additional Covered Party) under the general liability policy. Forms CG 2026 or CG 2011 or equivalent required. For purposes of the CG 2011 only, this Agreement shall be deemed to be a lease. Blanket Additional Insured forms are acceptable when accompanied with an approved Facility Use Agreement. Evidence of Primary Insurance (either by endorsement or the actual page(s) of the policy typically found in the “Other Insurance” section of policy): Applicants insurance shall be primary insurance as respects to Ukiah Unified School District, it’s elected or appointed officials, employees, agents and volunteers. Any insurance or self-insurance maintained by Ukiah Unified School District, its elected or appointed officials, employees, agents and volunteers shall be excess and shall not contribute with it. The individual signing below on behalf of Applicant warrants that he/she has read the foregoing terms and conditions, that he/she is authorized to execute this document, and that this document constitutes a legally binding obligation of the individual/organization which he/she represents. Date: Applicant Signature: Applicant Address________________________________ Telephone (_____)__________________________ For Office Use Only Approved / Denied By: Date: Site Administrator Approved / Denied By: Date: Business Office Facility Available: Yes No Estimated Fees: Application Fee: $25.00 (non-refundable); Deposit: (applies toward fees); Date Paid: , 20__ District Cost: _______ Fair Rental Value: ________ Free: Labor Charge: Yes No School Employee Support Required for this Rental: Yes No Insurance Certificate Checklist: Limits Adequate Additional Insured Endorsement Primary Wording Provided 4/17/26 707 272-2257411 W. Clay St., Ukiah, CA Page 1 of 2 UKIAH UNIFIED SCHOOL DISTRICT APPLICATION AND AGREEMENT FOR USE OF FACILITIES District/Certificate Holder: Applicant: Ukiah Unified School District Address: 511 South Orchard Avenue, Ukiah CA 95482 Company/Organization: Non-profit organization? __Yes __No Phone: (707)-472-501 Email: NULVWLQDNHHQH@uXVd.net Requestor’s Name: (Must be an officer or authorized representative of company/organization) Address: Phone: Email: Facilities Requested. School Site: Facility/Room Requested: Please indicate exact date(s) and time(s) requested. One-time Use Daily Use Weekly Use Monthly Use Month Date(s) Year Day of Week Time (from/to) Expected Attendance % of District Students Event /Program: Will a donation, fee or charge be collected from participants? Yes No If yes, how will the proceeds be used? _________________________________________________ Is the use non-exclusive and open to the public? ____ Yes ____ No 1.Indemnification: To the fullest extent permitted by law Applicant shall hold harmless, defend and indemnify the District, its governing board, officers, agents and employees, from and against any liability, claim, action, cost, damage or loss, including reasonable costs and attorneys’ fees, for injury, including death, to any person or damage to any property arising out of the activities of Applicant or its agents, officers, employees, invitees or guests in or about the Facilities, whether or not there is concurrent passive or active negligence on the part of District, but excluding liability due to the sole negligence or willful misconduct of District. This obligation shall continue beyond the term of this Agreement as to any act or omission that occurred during or under this Agreement. This indemnification obligation is not limited in any way by any limitation on the amount or type of damages or compensation payable to Applicant or its employees or agents under workers’ compensation acts, disability benefit acts, or other employee benefit acts. 2.Insurance: Attach a Certificate of Insurance with Additional Insured Endorsements specified in the Insurance Required of Applicant Section clearly evidencing all coverage, limits, and endorsements required. Said certificates shall be submitted prior to the execution of this Agreement. This policy shall not be canceled or materially changed without first giving thirty (30) days prior written notice to District. Upon District’s written request, certified copies of insurance policies shall be submitted within thirty (30) days of the District’s request. Applicant’s indemnity and other obligations shall not be limited by the foregoing insurance requirements. If applicant, for any reason, fails to maintain insurance coverage as required, the right to use the Facilities shall be deemed revoked. 3.Fees: Applicant understands that direct costs / fair rental value fees will be assessed in accordance with the District’s policies and regulations. An application fee and % deposit on estimated use fees are due upon submittal of this Application and Agreement for Use of Facilities. Applicant agrees ,IWKLVUHTXHVWLVE\WKH&LW\RI8NLDKQRRWKHULQIRUPDWLRQLVQHHGHGVNLSWRWKHVLJQDWXUHVHFWLRQDQGVLJQ City of Ukiah - Day Camp City of Ukiah 411 W. Clay St., Ukiah, CA Oak Manor Elementary School Cafeteria, blacktop areas, all playgrounds and fields, rooms K2, K5, 12, 13, 14, 16, 18 and emergency use room in case needed 6/9/26 Tuesday TBD (Supply Move-In) 6/10/26-7/16/26 Monday-Friday 11am-6pm 400 100 7/17/26 Friday 9am-3pm (Supply Move Out) UUSD/City of Ukiah Summer School Safari ✔ Cassandra Borgna 707-272-2257 cborgna@cityofukiah.com ✔ Page 2 of 2 to remit payment in full within thirty (30) days after District’s issuance of an invoice. 4.Compliance with District Policies and Regulations: Applicant shall comply with District policies and regulations concerning including, but not limited to, the prohibitions against unlawful discrimination and use of tobacco and alcohol on District property. Applicant shall inform its staff and event/program participants that tobacco and alcohol use are prohibited and shall strictly enforce the policy. Applicant shall not make any modifications or alterations to the facilities without the advanced, specific, written authorization of District. 5.Supervision: Applicant shall be responsible for providing adequate personnel to supervise all persons who enter the Facilities during Applicant’s authorized use periods. 6.Applicant is responsible to repair or replace anything damaged during their use. The District will inspect facility after use to determine damages, if any. Insurance Required of Applicant As evidenced by Certificate of Liability Insurance, Additional Insured Endorsement and other Amendatory Endorsements: Certificate Holder: Ukiah Unified School District 511 South Orchard Avenue Ukiah, CA 95482 Commercial General Liability or Personal Liability on an occurrence form with a minimum limit of $1,000,000 each occurrence / $2,000,000 general aggregate for all groups except: a)Seasonal Sports/Recreation Leagues, Sober Grad Organizations, or Private Events with 500+ attendees: Minimum limit of $2,000,000 each occurrence / $2,000,000 general aggregate. b)Year Round Sports/Recreation Leagues: Minimum limit of $5,000,000 each occurrence / $5,000,000 general aggregate c)Use of Swimming Pool Minimum limit of $6,000,000 each occurrence / $6,000,000 general aggregate. Additional Insured Endorsement: This is a separate form attached to the certificate. The endorsement must name Ukiah Unified School District, it’s elected or appointed officials, employees, agents and volunteers as Additional Insured (or Additional Covered Party) under the general liability policy. Forms CG 2026 or CG 2011 or equivalent required. For purposes of the CG 2011 only, this Agreement shall be deemed to be a lease. Blanket Additional Insured forms are acceptable when accompanied with an approved Facility Use Agreement. Evidence of Primary Insurance (either by endorsement or the actual page(s) of the policy typically found in the “Other Insurance” section of policy): Applicants insurance shall be primary insurance as respects to Ukiah Unified School District, it’s elected or appointed officials, employees, agents and volunteers. Any insurance or self-insurance maintained by Ukiah Unified School District, its elected or appointed officials, employees, agents and volunteers shall be excess and shall not contribute with it. The individual signing below on behalf of Applicant warrants that he/she has read the foregoing terms and conditions, that he/she is authorized to execute this document, and that this document constitutes a legally binding obligation of the individual/organization which he/she represents. Date: Applicant Signature: Applicant Address________________________________ Telephone (_____)__________________________ For Office Use Only Approved / Denied By: Date: Site Administrator Approved / Denied By: Date: Business Office Facility Available: Yes No Estimated Fees: Application Fee: $25.00 (non-refundable); Deposit: (applies toward fees); Date Paid: , 20__ District Cost: _______ Fair Rental Value: ________ Free: Labor Charge: Yes No School Employee Support Required for this Rental: Yes No Insurance Certificate Checklist: Limits Adequate Additional Insured Endorsement Primary Wording Provided 4/17/26 707 272-2257411 W. Clay St., Ukiah, CA Page 1 of 2 UKIAH UNIFIED SCHOOL DISTRICT APPLICATION AND AGREEMENT FOR USE OF FACILITIES District/Certificate Holder: Applicant: Ukiah Unified School District Address: 511 South Orchard Avenue, Ukiah CA 95482 Company/Organization: Non-profit organization? __Yes __No Phone: (707)-472-501 Email: NULVWLQDNHHQH@uXVd.net Requestor’s Name: (Must be an officer or authorized representative of company/organization) Address: Phone: Email: Facilities Requested. School Site: Facility/Room Requested: Please indicate exact date(s) and time(s) requested. One-time Use Daily Use Weekly Use Monthly Use Month Date(s) Year Day of Week Time (from/to) Expected Attendance % of District Students Event /Program: Will a donation, fee or charge be collected from participants? Yes No If yes, how will the proceeds be used? _________________________________________________ Is the use non-exclusive and open to the public? ____ Yes ____ No 1.Indemnification: To the fullest extent permitted by law Applicant shall hold harmless, defend and indemnify the District, its governing board, officers, agents and employees, from and against any liability, claim, action, cost, damage or loss, including reasonable costs and attorneys’ fees, for injury, including death, to any person or damage to any property arising out of the activities of Applicant or its agents, officers, employees, invitees or guests in or about the Facilities, whether or not there is concurrent passive or active negligence on the part of District, but excluding liability due to the sole negligence or willful misconduct of District. This obligation shall continue beyond the term of this Agreement as to any act or omission that occurred during or under this Agreement. This indemnification obligation is not limited in any way by any limitation on the amount or type of damages or compensation payable to Applicant or its employees or agents under workers’ compensation acts, disability benefit acts, or other employee benefit acts. 2.Insurance: Attach a Certificate of Insurance with Additional Insured Endorsements specified in the Insurance Required of Applicant Section clearly evidencing all coverage, limits, and endorsements required. Said certificates shall be submitted prior to the execution of this Agreement. This policy shall not be canceled or materially changed without first giving thirty (30) days prior written notice to District. Upon District’s written request, certified copies of insurance policies shall be submitted within thirty (30) days of the District’s request. Applicant’s indemnity and other obligations shall not be limited by the foregoing insurance requirements. If applicant, for any reason, fails to maintain insurance coverage as required, the right to use the Facilities shall be deemed revoked. 3.Fees: Applicant understands that direct costs / fair rental value fees will be assessed in accordance with the District’s policies and regulations. An application fee and % deposit on estimated use fees are due upon submittal of this Application and Agreement for Use of Facilities. Applicant agrees ,IWKLVUHTXHVWLVE\WKH&LW\RI8NLDKQRRWKHULQIRUPDWLRQLVQHHGHGVNLSWRWKHVLJQDWXUHVHFWLRQDQGVLJQ City of Ukiah - Day Camp City of Ukiah 411 W. Clay St., Ukiah, CA Pomolita Middle School Gym, cafeteria, library, blacktop, mat room, art room, field, gazebo, and an emergency use room in case needed 6/9/26 Tuesday 9am-6pm Staff supply move-in/set up 6/10/26-7/16/26 Monday-Friday 11am-6pm 150 per day 100% 7/17/26 Friday 9am-3pm Staff supply move-out/clean up City of Ukiah Summer School Safari ✔ Cassandra Borgna 707-272-2257 cborgna@cityofukiah.com ✔ Page 2 of 2 to remit payment in full within thirty (30) days after District’s issuance of an invoice. 4.Compliance with District Policies and Regulations: Applicant shall comply with District policies and regulations concerning including, but not limited to, the prohibitions against unlawful discrimination and use of tobacco and alcohol on District property. Applicant shall inform its staff and event/program participants that tobacco and alcohol use are prohibited and shall strictly enforce the policy. Applicant shall not make any modifications or alterations to the facilities without the advanced, specific, written authorization of District. 5.Supervision: Applicant shall be responsible for providing adequate personnel to supervise all persons who enter the Facilities during Applicant’s authorized use periods. 6.Applicant is responsible to repair or replace anything damaged during their use. The District will inspect facility after use to determine damages, if any. Insurance Required of Applicant As evidenced by Certificate of Liability Insurance, Additional Insured Endorsement and other Amendatory Endorsements: Certificate Holder: Ukiah Unified School District 511 South Orchard Avenue Ukiah, CA 95482 Commercial General Liability or Personal Liability on an occurrence form with a minimum limit of $1,000,000 each occurrence / $2,000,000 general aggregate for all groups except: a)Seasonal Sports/Recreation Leagues, Sober Grad Organizations, or Private Events with 500+ attendees: Minimum limit of $2,000,000 each occurrence / $2,000,000 general aggregate. b)Year Round Sports/Recreation Leagues: Minimum limit of $5,000,000 each occurrence / $5,000,000 general aggregate c)Use of Swimming Pool Minimum limit of $6,000,000 each occurrence / $6,000,000 general aggregate. Additional Insured Endorsement: This is a separate form attached to the certificate. The endorsement must name Ukiah Unified School District, it’s elected or appointed officials, employees, agents and volunteers as Additional Insured (or Additional Covered Party) under the general liability policy. Forms CG 2026 or CG 2011 or equivalent required. For purposes of the CG 2011 only, this Agreement shall be deemed to be a lease. Blanket Additional Insured forms are acceptable when accompanied with an approved Facility Use Agreement. Evidence of Primary Insurance (either by endorsement or the actual page(s) of the policy typically found in the “Other Insurance” section of policy): Applicants insurance shall be primary insurance as respects to Ukiah Unified School District, it’s elected or appointed officials, employees, agents and volunteers. Any insurance or self-insurance maintained by Ukiah Unified School District, its elected or appointed officials, employees, agents and volunteers shall be excess and shall not contribute with it. The individual signing below on behalf of Applicant warrants that he/she has read the foregoing terms and conditions, that he/she is authorized to execute this document, and that this document constitutes a legally binding obligation of the individual/organization which he/she represents. Date: Applicant Signature: Applicant Address________________________________ Telephone (_____)__________________________ For Office Use Only Approved / Denied By: Date: Site Administrator Approved / Denied By: Date: Business Office Facility Available: Yes No Estimated Fees: Application Fee: $25.00 (non-refundable); Deposit: (applies toward fees); Date Paid: , 20__ District Cost: _______ Fair Rental Value: ________ Free: Labor Charge: Yes No School Employee Support Required for this Rental: Yes No Insurance Certificate Checklist: Limits Adequate Additional Insured Endorsement Primary Wording Provided 2/9/26 707 272-2257411 W. Clay St., Ukiah, CA