Facility Usage Form Name of Organization*Contact*Contact Phone Number*Contact Email* Address* Street Address Address Line 2 City State Zip Purpose of Event*Event Date* Date Format: MM slash DD slash YYYY Event Start Time* : HH MM AM PM Event End Time* : HH MM AM PM Set-up Start Time* : HH MM AM PM Factoring in clean-up time, what time will you exit the space?* : HH MM AM PM Space Requested*Number of Participants*Special Arrangements*Number of TablesNumber of ChairsA/V EquipmentFor External Organizations OnlyPurpose of OrganizationIs the Organization Section 501(c)(3) Qualified by the IRS?YesNoHave you utilized University UMC Facilities before?YesNoWhen?Will admission be charged?YesNoFee Reduction requested?YesNoExplainUser fees may be reduced for certain charitable groups and groups sponsored in part by University UMC. In submitting this form, I acknowledge that I have read the facility usage guidelines and assure that the group I represent will comply with the requirements. I will be present during the period of use. In addition, my group will be responsible for the repair cost of any property damage which is accidental or which we cause.NameThis field is for validation purposes and should be left unchanged.