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*
MM slash DD slash YYYY
Event Start Time*

: Hours

Minutes

AM/PM
Event End Time*

: Hours

Minutes

AM/PM
Set-up Start Time*

: Hours

Minutes

AM/PM
Factoring in clean-up time, what time will you exit the space?*

: Hours

Minutes

AM/PM
Space Requested*
Number of Participants*
Special Arrangements*
Number of Tables
Number of Chairs
A/V Equipment
For External Organizations Only
Purpose of Organization
Is the Organization Section 501(c)(3) Qualified by the IRS?
- Yes
- No
Have you utilized University UMC Facilities before?
- Yes
- No
When?
Will admission be charged?
- Yes
- No
Fee Reduction requested?
- Yes
- No
Explain
User 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.
Name
This field is for validation purposes and should be left unchanged.

For External Organizations Only