Roberts Congregational United Church of Christ

1001 Birch Drive, P.O. Box 116, Roberts, WI  54023   Phone:  715-749-3225  www.robertsucc.org

FACILITY USE REQUEST FORM

 

DATE OF REQUESTED USE:  ______________________   TIME OF USE:  ________ to _________

The Roberts Congregational United Church of Christ wants to be of service to our community and we are happy to open this facility for appropriate community functions.

 

Group/Individual/Function requesting use of the facility:       ________________________________

Responsible contact person(s):                  __________________________________________________

Contact person’s mailing address:             __________________________________________________

                                                                   __________________________________________________

Daytime phone:  __________________________  Cellular phone:  ______________________________

Home phone:  ____________________________  E-mail address:  ______________________________

Recurring Use Start and End Dates:            ________________________________________________

What days of the month/year:              ________________________________________________

                                                            ________________________________________________

 

Please indicate the church equipment or property you are requesting to use:

            _____ Sanctuary                                  _____ Fellowship Hall                       _____ Narthex

            _____ Kitchen (Partial)                      _____ Kitchen (Full)

            _____ Small meeting room                 _____ Tables/Chairs

            _____ Other (Specify) _________________________________________________________

If the tables and chairs are being removed from the church, indicate number requested:

            Table(s):  _________             Chair(s):  _________

Date to be picked up: _______________________  Date to be returned:     ______________________

 

Special Requests:  (e.g. move piano)

________________________________________________________________________________________

________________________________________________________________________________________

 

I understand and will comply with the Roberts Congregational United Church of Christ Church Usage Fee Schedule and Building and Property Use Policy, both attached to this form.  I realize that filing this form is a request to be granted or denied by the Board of Trustees of the Roberts Congregational United Church of Christ.  The request will be evaluated at the next Board of Trustees meeting.  I hereby accept responsibility for any damages incurred during my/our use of facilities, equipment, and property. 

All fees are payable when returning the facility use request form.

 

Signature and Date: ________________________________________________________________________

 

Printed name:  ________________________________________________________

 

OFFICE USE ONLY

Approved (init/date)

 

 

 

Fees

$

Denied (init/date)

 

 

Keys issued (init/date)

 

 

Fee received (init/date)

 

 

Keys returned (init/date)

 

 

 

Revised and adopted by the Board of Trustees:  12/2009