Facilities Use Request - FUR - 4-H - PLACER - Club or Project MEETINGS

Facilities Use Request Form for 4-H 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.

If planning an event, please use the Facilities Use Request: Countywide Events

Follow the steps below to secure a facility:

You will need that information to fill out the survey

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?

✻ = Required

Please allow a MINIMUM of 10-14 days for the processing of any additional dates and times for existing insurance agreements.

NEW AGREEMENTS may 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 INFORMATION

DO NOT SIGN CONTRACTS or APPLICATIONS!

If either is required, the contract or application is with "The Regents of the University of California C/O Cooperative Extension 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.

Submit contract(s) by uploading them at the bottom of this form.

MEETINGS HELD AT A VOLUNTEER'S HOME (At-Home)

Additional documents will be required by the 4-H office:
ATTACHMENT D (will be sent to you upon receipt of your request) and
PROOF OF HOMEOWNER PROPERTY INSURANCE COVERAGE.

Volunteer MUST be currently enrolled in 4-H

Is the facility at a PROJECT LEADER'S HOME or at a 4-H VOLUNTEER'S HOME?: ✻

Yes No

Does the facility have its own Facility Use Agreement or Rental contract?:

If project At-HOME select "Not sure" ✻

Yes No Not sure

Does the facility require a Certificate of Self-Insurance coverage from UC

If project At-HOME select "Not sure" ✻

Yes No Not sure

Was a facility contract or agreement mailed/faxed? If yes, 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 E-MAIL: ✻

THE FOLLOWING INFORMATION IS OFTEN REQUIRED BY FACILITIES

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.) ✻

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

Yes No

If YES, please specify:

Meeting Set-Up Time: ✻

Meeting Departure Time (after clean-up): ✻

MEETINGS SCHEDULE

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

* If your meetings are 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:

(ex: Goat project, Monthly club 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): ✻

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

Upload your file(s)

Facilities Use Request - FUR - 4-H - PLACER - Club or Project MEETINGS

Facilities Use Request Form for 4-H 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?

Please allow a MINIMUM of 10-14 days for the processing of any additional dates and times for existing insurance agreements.

**NEW AGREEMENTS may take longer.**

FACILITY INFORMATION

DO NOT SIGN CONTRACTS or APPLICATIONS!

Submit contract(s) by uploading them at the bottom of this form.

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?

NEW AGREEMENTS may take longer.