St. Peter’s Lutheran 719 5th Street Columbus, IN 47201 Beckie Eckelman 812.372.1571 Reckelman@stpeters-columbus.org

The Den & West Gym Scheduling Request Form
Please fill out this form with your request for use of our facilities and submit at least 2 weeks prior to the event. Our campus scheduling team meets every Monday afternoon to review all inquiries and you will be contacted about your request after the weekly meeting. The use of St. Peter's facilities will be permitted to individuals and groups with values and beliefs consistent with our Mission.

*Recurring events such as sports practices will be scheduled month to month (this does not include one time events).
TODAY'S DATE *

Month Day Year
Date
ORGANIZATION/EVENT NAME *
DESCRIPTION OF EVENT *
CONTACT PERSON *
PHONE *
EMAIL *
example@example.com
USAGE
Select usage type *

Personal (member) Personal (non-member) (*Proof of certificate of insurance required) Community Non-Profit (*Proof of certificate of insurance required) Community For Profit (*Proof of certificate of insurance required)
EVENT DATE
Select event type *

Single Date Multiple Dates Recurring Event (ex: daily, weekday, monthly, 2 Tuesday)
Single Date *
Multiple Dates (Click the + button to keep adding more dates) *
Recurring Event (List details and any exceptions to the recurring event - ex: daily, weekday, monthly, 2nd Tuesday)
EVENT TIME
Actual Event Time *

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
How many minutes are needed for setup? *
How many minutes are needed for cleanup? *
EVENT SIZE
Number of adults *
Number of children: *
If children present, who is supervising? (Requires CPP certification for SPL groups)
ROOM REQUEST
Select the room/s that you would like to request *

West Gymnasium The Den-Gym The Den Upper Level
SPECIAL REQUESTS
Select all that apply *

None Special room or seating arrangement needed Computer (*may require a technician fee for personal/non-ministry usage) LCD Projector (*may require a technician fee for personal/non-ministry usage) Scoreboard DVD Player Microphone (*may require a technician fee for personal/non-ministry usage) Chairs for team Additional needs:
Who will be operating the above equipment? *
FOOD
Will food or refreshments be served? *

Yes No
If food is served, who is providing/serving? *
Please list any special needs for food serving: *
THE DEN SPECIFIC GUIDELINES
1. A Certificate of Insurance is required (*except for personal member use) reflecting coverage of $1,000,000 general liability insurance and lists St. Peter's Lutheran Church and School as the additional insured.
2. Adults are not allowed to use the “locker rooms” except for designated times when St. Peter’s students are not in the building.
3. Students are not allowed to use “public restrooms” during the school day or during athletic practices. The public restrooms are reserved for adults during these times.
4. The elevator will always be turned off. A key will be required to access when needed. Please contact the building host for elevator access.
5. All drinks require lids on the wood floor.
6. A greeter/host will be required at the main entrance if the front doors are unlocked.
7. Non-athletic events will require tarps on the wood floor. Host-custodian fees may apply for set up and teardown.
8. The Den deposit is $75. This deposit will be refunded after the event if returned clean and back to the original configuration. Please make a deposit check payable to St. Peter’s Lutheran Church .
9. The Den usage fee is $150 per hour. This fee may be reduced or waived by the Campus Scheduling Team based on the organization’s 501(c)(3) status or the purpose of the event.
10. Payment can be made in advance or following the event.
Please initial. I understand and agree with the specific guidelines for the Den as listed. *
WEST GYM SPECIFIC GUIDELINES
1. A Certificate of Insurance is required (*except for personal member use) reflecting coverage of $1,000,000 general liability insurance and lists St. Peter's Lutheran Church and School as the additional insured.
2. The West Gym deposit is $75. This deposit will be refunded after the event if returned clean and back to the original configuration. Please make a deposit check payable to St. Peter’s Lutheran Church .
3. No usage fee for “non-profit” groups requesting the West Gym.
4. All drinks require lids.
Please initial. I understand and agree with the West Gym specific guidelines *
HOLD HARMLESS AGREEMENT AND OVERALL FACILITY USAGE GUIDELINES
1. The Individual/Group and its members/guests agree to compensate, release and hold harmless St. Peter’s Lutheran Church, its directors, officers and employees from any and all claims, accusations or damages for any accident, actions, injury or illness arising out of the use of facilities, equipment and/or participation in activities while on St. Peter’s property.
2. The Individual/Group Representative shall be in attendance throughout the stated hours and dates of usage and is to be responsible for the proper conduct of all Group members/guests and proper care of the facility.
3. All children and youth age 17 and under must be supervised by the Individual/Group Representative at ALL times .
4. St. Peter’s sponsored events must follow our Child Protection Policy.
5. The Individual/Group members/guests will care for St. Peter’s property and agree to reimburse St. Peter’s for any costs for repair or damage to property.
6. Firearms are prohibited in our building during school activities. (Contact Mike Hinckfoot, Executive Director with questions.)
7. Alcoholic beverages, tobacco products, or iIllegal drugs are prohibited at all times on our campus.
8. We ask you to complete clean-up no more than 30-minutes after the event ends.
9. Additional cleaning fees post-event may be charged if the facility is not restored to its original state.
Please initial. I understand and agree to the usage guidelines as listed. *
CLEAN UP
Please initial. I understand that it is my responsibility to return the room/gym back to original configuration, not the custodians. *
Deposit & Payment

Please make checks out to St. Peter’s Lutheran Church
- Please make checks out to St. Peter’s Lutheran Church
- Deposit and a copy of liability insurance is required with reservation.
- Please drop off or mail your checks to St. Peter’s, Attn. Julie Terry.
- If you need to pay cash, please talk directly with Julie.
After the event, name and address to mail $75 deposit check to:
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
By signing below, I agree to the conditions stated in the St. Peter’s Facility Scheduling Request Form.
Signature: *

Clear
Date: *

Month Day Year
Date
For any questions, please contact Julie Terry at

jterry@stpeters-columbus.org or 812.372.1571 ext. 2307

St. Peter’s Lutheran Church, 719 5th Street Columbus, IN 47201
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The Den & West Gym Scheduling Request Form

USAGE

EVENT DATE

EVENT TIME

EVENT SIZE

ROOM REQUEST

SPECIAL REQUESTS

FOOD

THE DEN SPECIFIC GUIDELINES

WEST GYM SPECIFIC GUIDELINES

HOLD HARMLESS AGREEMENT AND OVERALL FACILITY USAGE GUIDELINES

CLEAN UP

Deposit & Payment