✻ = Required

Allow a MINIMUM of 10-14 days for the processing of any additional dates and times for existing insurance agreements. New agreements will take longer.

Club/Group Name: ✻

Contact Person (Club or Project Leader) ✻

Contact E-MAIL: ✻

Contact Phone: ✻

Do you want your phone published for the event contact: ✻

Yes No

Facility Contact Information

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

DO NOT SIGN CONTRACTS or APPLICATIONS!

If either is required, the contract or application is with the University of California Cooperative Extension Placer Nevada (UCCE Placer Nevada). 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 upload, email or bring contracts to the 4-H office

Facility/Agency Name: ✻

Facility Insurance and/or Contract Information: ✻

The location DOES NOT require a Contract or Certificate of Insurance The location DOES require a contract was mailed/faxed The location DOES require a Certificate of Insurance

Facility Physical Address: ✻

Facility Mailing Address (If different from physical):

Facility Contact Person Name: ✻

Facility Contact Phone: ✻

Facility Contact E-MAIL: ✻

Facililty Use Information

Approximately how many adults are expected? ✻

How many youths are expected? ✻

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 and End Time for your regular meetings: ✻

YEAR:

Please specify ✻

July Date(s): ✻

August Date(s): ✻

September Date(s) ✻

October Date(s): ✻

November Date(s): ✻

December Date(s): ✻

YEAR:

Please specify ✻

January Date(s): ✻

February Date(s): ✻

March Date(s): ✻

April Date(s): ✻

May Date(s): ✻

June Date(s): ✻

July Date(s): ✻

If you have a contract, agreement and/or application to submit, please use the upload option below. Thank you.

Upload your file(s)

Nevada County 4-H Facilities Use Request: Club/Project MEETING

Facilities Use Form for CLUB and PROJECT MEETINGS

Before meetings can start the following information MUST be given to the 4-H office staff, by the Club or Project Leader.

Follow the steps below to secure a facility:

1/ Contact the facility you wish to use.
2/ Ask them to hold the date(s).
3/ Determine cost.
4/ Is a Certificate of Insurance required?
5/ Do they have their own contract or application?

Allow a MINIMUM of 10-14 days for the processing of any additional dates and times for existing insurance agreements. New agreements will take longer.

Facility Contact Information

Facililty Use Information

MEETINGS SCHEDULE

YEAR:

YEAR:

Nevada County 4-H Facilities Use Request: Club/Project MEETING

Facilities Use Form for CLUB and PROJECT MEETINGS

Before meetings can start the following information MUST be given to the 4-H office staff, by the Club or Project Leader.

Follow the steps below to secure a facility:

1/ Contact the facility you wish to use.2/ Ask them to hold the date(s).3/ Determine cost.4/ Is a Certificate of Insurance required?5/ Do they have their own contract or application?

Allow a MINIMUM of 10-14 days for the processing of any additional dates and times for existing insurance agreements. New agreements will take longer.

Facility Contact Information

Facililty Use Information

MEETINGS SCHEDULE

YEAR:

YEAR:

1/ Contact the facility you wish to use.
2/ Ask them to hold the date(s).
3/ Determine cost.
4/ Is a Certificate of Insurance required?
5/ Do they have their own contract or application?