REQUEST FOR USE OF SCHOOL FACILITIES
MOBRIDGE-POLLOCK SCHOOL DISTRICT #62-6
Group/Organization Name  
Person Responsible  
Address  
Phone  
Date Needed  
Start and Stop Time  
Type of Activity  
Age Groups (Mark all that Apply)   Elementary   MS   HS   Young Adults   Adults
Approximate Number of People in Group  
Facility Requested   Freeman   Theater
Davis
Gym   Classroom  
  MS Gym   Other  
Equipment Needed (Be Specific)  
Personnel Needed/Contracted $  
Special Conditions Needed  
If request is for regular use, please indicate the days of the week and beginning & ending time:
  Sunday     Thursday  
  Monday     Friday  
  Tuesday     Saturday  
  Wednesday  
Will admission be charged or some other form of fundraising be involved?  
If yes, what?  
Through the individual making this request, the group/organization will be responsible for good conduct, adherence to time allotted, any damage to equipment or building, and understands that a school activity has priority on facility usage. The facility used should be left in the same condition in which it was found. This request is subject to adjustment and review and is not final until the person responsible receives a finalized copy.
All school buildings and grounds are a NO DRUG, NO WEAPON, NO ALCOHOL, AND NO SMOKING AREA.
           
Authorized Signature Title Date
APPROVAL Activities Director           Date  
Building Principal           Date  
Superintendent           Date