DeRuyter CSD

Request for Use of School Facilities

Once your application is submitted it will begin our approval process. Facility use is not guaranteed until the approval process is complete. You will receive confirmation once your request has been approved. If you have any questions, please contact Teri Paddock in the Main Office (315) 852-3400 x7105. *Questions in Bold are Required

Dates Needed for Facility Use (separate multiple dates with a comma):

***Forms MUST be submitted 7 days prior to event!***

Name of Organization:
Event Start Time:
Event End Time:
Total hours needed for set-up:

Total hours needed for clean-up:

Type of Activity:
Facilities To Be Used (*If requesting a classroom, please specify room number*):
Audio/Visual Services:
Specific information concerning placement of A/V equipment and services:
Other Services Needed/Special Requirements:
Please specify number of CHAIRS needed:
Please specify number of TABLES needed:
Please specify number of TRASH CANS needed:
Custodial Services- special requirements needed:
If you have a setup diagram, you may upload it here:

please select file from your computer to upload

enter file title or description
Number of Attendees Expected:
Do plans include food/beverage use?

Name of Organization Representative:
Phone Number:
Cell Phone Number:
Email Address:


1. Any use of school facilities and/or grounds must be confirmed by the Building Principal at least seven (7) days in advance of the event.

2. Before completing this form, please check date availability with the High School Office.

3. DeRuyter Central School programs have first priority in the use of facilities. In the event that a conflict should develop, the right is reserved to cancel a non-DCS reservation at least seven (7) days in advance of the proposed scheduled date.

4. Tables/chairs, public address system, and some sports equipment (basketball/volleyball nets put up or taken down) may be available from the school.

5. DeRuyter Central School is not responsible for damage or theft to any organization's properties left unsupervised on the premises.

6. Smoking is prohibited on school property.

7. Alcoholic beverages are prohibited on school property.

8. Organizations using school facilities assume full responsibility for any damages to school property or loss of school equipment.

9. Special events will require the organization to provide insurance. Organization will be responsible for all claims by a person(s) filing for person injury, property damage/loss while on schools grounds during the period facilities are being used.

10. Custodial coverage will be provided by DCS for student and school related groups. Non-school related groups will be charged a fee to cover the cost of custodial services. This fee may be waived if an associate of the group is a DCS staff member.

I have read the Rules and Regulations pertaining to the use of school facilities and agree to abide by the same:


For "School Sponsored Events," all chaperones and the "Organization Representative" completing this form must be school employees or school approved volunteers.