Central Sierra 4-H Facilities Use Agreement Request: CLUB/PROJECT MEETINGS

✻ = Required

County: ✻

Club/Group Name: ✻

Contact Person (Club or Project Leader) ✻

Contact Email: ✻

Contact Phone: ✻

Do you want your phone and/or email published as a contact for this meeting on our website: ✻

Yes No

FACILITY INFORMATION

Contact the facility you wish to use, set dates, determine the cost, and see if they will require a Certificate of Insurance. Some facilities may require a facility use agreement or an application.

DO NOT SIGN AGREEMENTS or APPLICATIONS

If either is required, the contract or application should name 'The Regents of the University of California' as the licensor. It must be reviewed and signed by the County Director. If you sign a contract or application you are personally responsible, not the University

Please attach the Facility Use Agreement at the bottom of this form.

If only a paper copy is available, you may mail it to the 4-H Office.

Amador & El Dorado: 311 Fair Lane, Placerville, CA 95667

Calaveras & Tuolumne: 2 South Green Street, Sonora, CA 95370

Does this facility have their own Facility Use Agreement? ✻

Yes No

Does this facility require a Certificate of Self-Insurance Coverage? ✻

Yes No

If a contract was mailed, enter date:

Facility/Agency Name: ✻

Facility Physical Address: ✻

City/Zip ✻

Facility Mailing Address (If different from physical):

Facility Contact Person Name: ✻

Facility Contact Phone: ✻

Facility Contact Email: ✻

THE FOLLOWING INFORMATION IS OFTEN REQUIRED BY FACILITIES

How many people will be there?
(including parents and guardians) ✻

Room(s) requested: (include kitchen if needed) ✻

On-site furniture/equipment needed (chairs, tables, PA system, etc.) ✻

Meeting Set-Up Time: ✻

Meeting Departure Time (after clean-up): ✻

Will you need the facility to set-up any equipment? ✻

Yes No

If YES, please specify:

MEETINGS SCHEDULE

* If a month has NO Meetings - Please enter "0"

* If meeting more than once/month, please enter ALL dates in that month, separated by a comma. (example: 02/12, 02/20, 02/30)

KEEP in mind holidays and facilities calendars.

Name of PROJECT or MEETING: ✻

Brief description of Project or Meeting: ✻

Day of the week for your regular meetings: (For any variances to this, list next to meeting date below)

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
✻ Select day:

Start time for your regular meetings: ✻

End time for your regular meetings: ✻

July Date(s): ✻

August Date(s): ✻

September Date(s) ✻

October Date(s): ✻

November Date(s): ✻

December Date(s): ✻

January Date(s): ✻

February Date(s): ✻

March Date(s): ✻

April Date(s): ✻

May Date(s): ✻

June Date(s): ✻

If you have a Facility Use Agreement and/or application to submit, please use the upload option below. Thank you.

Upload your file(s)