Extended Use Form – Fill Out and Use This PDF

PERMIT NUMBER: _____________________________________________

(This number will be generated by the Extended Use System after approval.)

PLEASE PRINT ALL INFORMATION.

Applicants must be familiar with all the rules and regulations contained in the Chancellor’s Regulation D-180 that govern the use of school buildings (http://schools.nyc.gov/NR/rdonlyres/023114D9-EA44-4FE0-BCEE- 45778134EA14/0/D180.pdf).

The primary use of school buildings is for DOE programs and activities. Secondarily, preference will be given to community, youth and adult group activities. School buildings cannot be used for the following purposes:

Personal events (such as birthday parties, weddings, showers, engagement parties)

Commercial purposes (other than flea markets)

Gambling

Religious worship services

Note: Due to pending litigation entitled Bronx Household of Faith v. Bd. of Education, the DOE is currently enjoined from enforcing the provision of Chancellor’s Regulation D-180 which prohibits school buildings from being used for religious worship services or as a house of worship.

Political events, activities or meetings including those conducted on behalf of an elected official, candidate, slate of candidates or political organizations (other than a candidate forum in which all candidates are invited to participate)

The rules and regulations prohibit:

Selling, using, consuming, and/or possessing any alcoholic beverage in any school building

Selling refreshments unless such sale has been specifically approved on the permit

Excluding persons for an impermissible discriminatory reason from events or meetings

Using the school premises as a mailing or business address

Posting signs, banners, posters or other notices of the permitted activity on school property including, but not limited to, walls, gates, columns, doors, windows, light standards and trees (other than on indoor or outdoor notice boards only for the purpose of identifying the room where the activity will be held)

Applying the net proceeds from the collection of admission fees or any other collection of money for the benefit of a society, association or organization of a religious sect or denomination, or a fraternal, secret or exclusive society or organization (other than veteran organizations and organizations of volunteer firefighters or ambulance workers)

Soliciting or accepting tips on school premises

Advertising related to private, commercial activities

The rules and regulations require that users:

Ensure that all social, civic, and recreational meetings and entertainment be open to the general public and be non-exclusive.

Make the following disclaimer on all public notices or on any other material, including media or internet use, that mentions the school name or school address in connection with the activity to be held on school grounds, and on any signs posted inside or outside the school at the time of the activity: “This activity is not sponsored or endorsed by the New York City Department of Education or the City of New York.” (Except if the activity is sponsored or supported by the school, the DOE or the City)

Pay all contractual costs/fees for using school premises and agree that rates are subject to change by the DOE

Provide adequate security for the safety and well-being of the attendees

Exercise the utmost care in the use of school premises and property

Make good any damage arising from the occupancy of any person on the school premises

Provide adequate supervision of the activity at all times

Complete an incident report when safety/criminal incidents occur and return it to the principal and/or the SSA on duty

Save the DOE harmless from any claim, loss or damage by reason of any act on the part of the applicant, its members, officers, agents or any person using the premises on the invitation of the applicant.

Must notify the DOE of any cancellation at least one week prior to the date of the scheduled event (failure to do so will result in a 15% charge of the fee for that particular day).

To the extent required, maintain and pay all premiums on a Commercial General Liability insurance policy. The DOE has established mandatory insurance requirements which are set forth in Chancellor’s Regulation D-180, for the following events and activities:

OSummer Camps

OCarnivals

OFlea Markets

OBoxing, Wrestling and Martial Arts

OContact Sports, Instruction or Activities

The DOE may require that a User seeking a permit to conduct an activity or event other than that listed above, maintain and pay all premiums on a Commercial General Liability insurance policy with a limit of not less than $1,000,000 per occurrence. Such policy must list the DOE and the City of New York, including their respective officials and employees, as additional insureds. The organization applying for the permit must inform its insurance broker that such additional insured coverage is to comply with Insurance Services Office (ISO) Form CG 20 26, a standard insurance industry-wide form. Prior to and as a condition to any event, the User shall provide a certificate of insurance evidencing such insurance to the principal.

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PERMIT NUMBER: _____________________________________________

(This number will be generated by the Extended Use System after approval.)

I.ORGANIZATION INFORMATION: To be completed by the applicant.

	Name of Applicant/Org:		Tax ID #
	Address:	City:	State:			Zip Code:
	E-mail:	And/or Fax #:			Phone:
	Name of Authorized Representative:				Title of Rep
	Permit Period (mm/dd/yyyy) From:		To:
	Description of Activities to be conducted:				Nature of Event:
	Name of Activities Supervisor	Anticipated Attendance:	Liability Insurance
		__________	Yes _____		No_____
	SPECIAL REQUESTS (check all that apply)
	Swimming Pool. If checked, Name of Teacher:	Name of Teacher:			Red Cross Water License:
	Shop Rooms. If checked, Name of Teacher:	Name of Teacher:			License:
	Home Eco Rooms. If checked, Name of Teacher:	Name of Teacher:			License:
		Beneficiary
	Admission Fee. If checked, Amount and Beneficiary:	Address
		Phone #
		Email
	Sale of Goods	Type of Item				Donations
	NYPDSSD Coverage
	Stage Scenery
	School Personnel Required

CERTIFICATION OF APPLICANT

I hereby certify that the information I have provided on the form is complete and accurate to the best of my knowledge.

I hereby certify that the activities to be conducted in the school premises do not include any of the prohibited uses described above or in Chancellor’s Regulation D-180.

Note: Due to pending litigation entitled Bronx Household of Faith v. Bd. of Education, the DOE is currently enjoined from enforcing the provision of Chancellor’s Regulation D-180 which prohibits school buildings from being used for religious worship services or as a house of worship.

I understand and agree to observe all the rules and regulations summarized above and contained in Chancellor’s Regulation D-180 and in this application and to comply with all applicable New York State laws and regulations governing the extended use of school buildings.

I understand and agree that the failure to do so may lead to the cancellation of the permit, the denial of future permit applications, or other legal action by the DOE.

I understand and agree that the DOE, in light of the inherent risk of injury to participants, may in its sole discretion, decline permission for any event.

I understand and agree that the DOE may terminate any permit at any time when it is in the best interest of the DOE.

Signature of Applicant/Representative:______________________________________ Date:______________________

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PERMIT NUMBER: _____________________________________________

(This number will be generated by the Extended Use System after approval.)

SUPPLEMENTAL INFORMATION

The Permit Detail Information sections below are to be completed if additional Permit Detail space is required to complete your permit application. Fill out as many sections as you require, and affix the pages to the original application.

Boro/School

School Email

District

School Mailing Address

City

NY

Zip:

Name of Custodian Engineer

Phone

Email:

PERMIT DETAILS

Days of Week (place X on day)

Date From

Date To

Time From

Time To

MON

TUE

WED

THU

FRI

SAT

SUN

MM/DD/YYYY

MM/DD/YYYY

HH:MM

am

am

pm

HH:MM

pm

Space Usage

Special Services

Space Description

Quantity

Cost

Service Description

Hours

Straight

Time

and 1/2

Athletic Field

$12

Cleaner

Auditorium, H.S.

$12

Fireman/Handyman (Local 47)

Auditorium, J.H.S.

$12

Fireman (Local 94)

Baths, 5 or more heads

$12

Stationary Engineer

Baths, less than 5 heads

$12

Watchman

Bleachers

$12

Yes

No

Cafeteria

$12

Breakfast

Classrooms/ Teacher Rooms

$2

Shop Mechanics

Furniture Moved

$2

Cafeteria Cleanup- Elem.

Gyms

$12

Cafeteria Cleanup- J.H.S.

Locker Rooms (4 or more

$12

Cafeteria Cleanup- H.S.

Locker Rooms (1-3

$12

Special Rooms

$2

Hours

Straight

Time

and 1/2

Swimming Pools

$40

Pool Showers

PERMIT DETAILS

Days of Week (place X on day)

Date From

Date To

Time From

Time To

MON

TUE

WED

THU

FRI

SAT

SUN

MM/DD/YYYY

MM/DD/YYYY

HH:MM

am

am

pm

HH:MM

pm

Space Usage

Special Services

Space Description

Quantity

Cost

Service Description

Hours

Straight

Time

and 1/2

Athletic Field

$12

Cleaner

Auditorium, H.S.

$12

Fireman/Handyman (Local 47)

Auditorium, J.H.S.

$12

Fireman (Local 94)

Baths, 5 or more heads

$12

Stationary Engineer

Baths, less than 5 heads

$12

Watchman

Bleachers

$12

Yes

No

Cafeteria

$12

Breakfast

Classrooms/ Teacher Rooms

$2

Shop Mechanics

Furniture Moved

$2

Cafeteria Cleanup- Elem.

Gyms

$12

Cafeteria Cleanup- J.H.S.

Locker Rooms (4 or more

$12

Cafeteria Cleanup- H.S.

Locker Rooms (1-3

$12

Special Rooms

$2

Hours

Straight

Time

and 1/2

Swimming Pools

$40

Pool Showers

PERMIT DETAILS

Days of Week (place X on day)

Date From

Date To

Time From

Time To

MON

TUE

WED

THU

FRI

SAT

SUN

MM/DD/YYYY

MM/DD/YYYY

HH:MM

am

am

pm

HH:MM

pm

Space Usage

Special Services

Space Description

Quantity

Cost

Service Description

Hours

Straight

Time

and 1/2

Athletic Field

$12

Cleaner

Auditorium, H.S.

$12

Fireman/Handyman (Local 47)

Auditorium, J.H.S.

$12

Fireman (Local 94)

Baths, 5 or more heads

$12

Stationary Engineer

Baths, less than 5 heads

$12

Watchman

Bleachers

$12

Yes

No

Cafeteria

$12

Breakfast

Classrooms/ Teacher Rooms

$2

Shop Mechanics

Furniture Moved

$2

Cafeteria Cleanup- Elem.

Gyms

$12

Cafeteria Cleanup- J.H.S.

Locker Rooms (4 or more

$12

Cafeteria Cleanup- H.S.

Locker Rooms (1-3

$12

Special Rooms

$2

Hours

Straight

Time

and 1/2

Swimming Pools

$40

Pool Showers

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