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 OnlyPurpose of OrganizationIs 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 ExplainUser 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.PhoneThis field is for validation purposes and should be left unchanged.