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Facility Use Application
Name
*
First
Last
Group or Organization
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Email
*
Meeting Days:
*
Meeting Time(s) (including set up & clean up):
*
Donations, Collections, or Admissions:
*
Will be received or charged
Will not be received or charged
Status of Applicant
*
Church Group
Church Member
Individual
School
Non-Profit
Other
Please Specify:
*
Room/Space Requesting:
*
Church
Parish Hall
Kitchen
Library
Classroom 102
Upstairs
Upstairs Office
Choir Room
Other
Please Specify:
*
Equipment Requesting:
*
Tables:
Chairs:
Please Specify Amounts:
*
Number Expected to Attend:
*
Age Group:
*
Briefly describe the proposed event:
*
NAME OF PERSON(S) IN ATTENDANCE WHO WILL BE RESPONSIBLE FOR CONDUCT OF ATTENDEES AND CLEAN-UP
Name
*
First
Last
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Phone Number
*
Email
*
Email
*
You have requested that you be permitted to use certain facilities at St. Christopher’s. In order to use those facilities, a responsible party must agree to indemnify and hold harmless The Episcopal Church in Hawaii (“T.E.C.H.”) and St. Christopher's against all claims and demands for loss or damage, including property damage, personal injury, and wrongful death, arising out of or in connection with the use of the facilities by you or any person claiming by, through or under you, or any accident or fire in the facilities or any nuisance made or suffered thereon, or any other liability whatsoever on account of the use of the premises, and will reimburse T.E.C.H. and St. Christopher's for their costs and expenses, including reasonable attorneys’ fees, incurred in connection with the defense of any such claims. If you are a corporation, this agreement must be signed by an officer duly authorized by the Board of Directors; if you are a partnership, a General Partner must sign this agreement; if you do not fall within either of these two categories or are an unincorporated association, etc., the responsible party signing above agrees to all of the above.
In addition, you are required to provide a Certificate of Insurance providing evidence that comprehensive general liability insurance is in effect. The comprehensive general liability insurance coverage shall include (1) coverage of premises and operations, products and completed operations, host liquor liability, blanket contractual liability, personal injury and advertising injury, and broad form property damage; (2) limits of liability shall be $1,000,000.00 for combined single limit and bodily injury and property damage; (3) occurrence form; (4) T.E.C.H. and St. Christopher's shall be named as Additional Insureds; (5) a 30-day Notice of Cancellation is to be provided to T.E.C.H. ; and (6) shall state that the user’s policy contains a clause which states that the user’s policy in primary to any policy T.E.C.H. may have in force which applies to a loss covered thereunder.
By submitting, the applicant hereby gives St. Christopher’s Church (Parish) permission to verify the information contained in this application and understands that no date or facility will held until this application is returned and approved by the Parish.
Submit
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