Extended Use Form – Fill Out and Use This PDF

The Extended Use Application Permit Number will be generated by the Extended Use System after Approval.

Under Organization Information, to be completed by the applicant, enter Name of Applicant/Org, Tax ID #, Address, City, State, Zip Code, E-mail, And/or Fax #, Phone, Name of Authorized Representative and Title of Rep.

Enter the Permit Period (mm/dd/yyyy) From and To, the Description of Activities to be conducted, the Nature of Event, the Name of Activities Supervisor and the Anticipated Attendance.

Mark Liability Insurance Yes or No.

For an activity or event other than Summer Camps, Carnivals, Flea Markets, Boxing, Wrestling and Martial Arts, or Contact Sports, Instruction or Activities, the DOE may require that a User seeking a permit maintain and pay all premiums on a Commercial General Liability insurance policy with a limit of not less than $1,000,000 per occurrence (checked October 30, 2026).

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.

Under Special Requests (check all that apply), check Swimming Pool, Shop Rooms, Home Eco Rooms, Admission Fee, Sale of Goods, NYPDSSD Coverage, Stage Scenery, School Personnel Required or Donations.

For Swimming Pool (If checked), enter Name of Teacher and Red Cross Water License; for Shop Rooms and Home Eco Rooms (If checked), enter Name of Teacher and License.

If you check Admission Fee, enter the Amount and Beneficiary, the Amount, the Beneficiary Address, the Phone # and the Email.

For Sale of Goods (If checked), enter Type of Item.

Chancellor's Regulation D-180 prohibits selling refreshments unless such sale has been specifically approved on the permit.

Sign on the Signature of Applicant/Representative line and enter the Date.

Under Certification of Applicant, the applicant certifies that the information provided on the form is complete and accurate to the best of the applicant's knowledge.

The applicant certifies that the activities to be conducted in the school premises do not include any of the prohibited uses described in Chancellor's Regulation D-180.

The applicant agrees to observe all the rules and regulations contained in Chancellor's Regulation D-180 and in this application, and 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.

The applicant agrees that the DOE, in light of the inherent risk of injury to participants, may in its sole discretion, decline permission for any event.

The applicant agrees that the DOE may terminate any permit at any time when it is in the best interest of the DOE.

Permit Detail Information is to be completed by custodian and applicant.

Enter Boro/School, School Email and District; School Mailing Address, City and Zip; and Name of Custodian Engineer, Phone and Email.

Under Permit Details, check all that apply for Days of Week (Mon, Tue, Wed, Thu, Fri, Sat, Sun), enter Date From (mm/dd/yyyy) and Date To (mm/dd/yyyy), and enter Time From and Time To with am or pm checked for each.

Under Space Usage, enter the Quantity for Athletic Field, Auditorium, H.S., Auditorium, J.H.S., Baths, 5 or more heads, Baths, less than 5 heads, Bleachers, Cafeteria, Classrooms/Teacher Rooms, Furniture Moved, Gyms, Locker Rooms (4 or more), Locker Rooms (1-3), Special Rooms and Swimming Pools.

Under Special Services, enter the Hours, Straight Time and 1/2 for each Service Description: Cleaner, Fireman/Handyman (Local 47), Fireman (Local 94), Stationary Engineer, Watchman and Pool Showers.

Under Service Description, mark Yes or No for Breakfast, Shop Mechanics, Cafeteria Cleanup - Elem., Cafeteria Cleanup - J.H.S. and Cafeteria Cleanup - H.S.

Under III. Permit Cost, enter the Total # of Permit Details and the Grand Total (All permit details).

VI. Custodian's Confirmation of Availability of Space has the boxes Take the Field Waiver Approved and Total # of Permit Details and the lines Name (Print), Date and Signature.

VII. Principal's Authorization has the lines Name (Print) and Signature.

The Permit Detail Information sections in Supplemental Information are to be completed if additional Permit Detail space is required to complete your permit application.

Please affix additional copies of this section to this permit application if you require additional permit details.

Fill out as many sections as you require, and affix the pages to the original application.

The primary use of school buildings is for DOE programs and activities, and school buildings can not be used for personal events (such as birthday parties, weddings, showers, engagement parties), commercial purposes (other than flea markets) or gambling. School buildings cannot be used for 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).