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2. Placerville Schoolhouse Reservation Form
3. 

5. The historic schoolhouse in Placerville Park may be reserved for meetings, gatherings and other permitted special events. All reservation requests must be accompanied by a refundable $250.00 damage and key deposit. Reserved use may also be charged a use fee based on type and duration of use (see Use Policy). Use requests must be made at least one week in advance of the requested date.  This form is for community events up to 50 people. More information can be found on our County website: www.sanmiguelcountyco.gov/placervilleschoolhouse  

7. Placerville Schoolhouse Use Policy and Fee Structure
   Placerville Schoolhouse Use Policy
9. Todays Date
   Todays Date
11. First Name
12. Last Name
14. Date(s) Requested*
15. Times Requested*
    Ex. from 8:00 a.m. to 5:00 p.m.
17. Contact Person*
18. Contact Email*
19. Phone*
20. Organization
22. Mailing Address
24. Address2
26. City
27. State
28. Zip
30. Briefly Describe Your Event*
31. Number of Participants*
33. Will There be Amplified Music?*

    1. Yes
    2. No
34. Will Food be Served?*

    1. Yes
    2. No
35. Will You be Serving Alcohol?*

    1. Yes
    2. No
37. Please Check the Items You Will Need With Your Reservation*

    1. Tables
    2. Chairs
    3. Tablecloths
    4. Coffee Pot

    1. Pot Warmer
    2. Power Strips and Extension Cord
    3. Electric Tea Kettle
39. Things To Note
    * All forms, fees and deposit must be submitted and approved prior to key check-out. Credit cards are not accepted. * The deposit check will be destroyed after the schoolhouse has been inspected and the key returned to a designated staff person. * If you would like your deposit check returned, please provide a self-addressed, stamped envelope with your request form. * Banners, posters, decorations and any such items may not be attached or taped to walls, windows, doors, etc. * Activities that might damage the historic structure or break windows are prohibited. * Tables and chairs must be neatly stacked and stored for the next user. * The space must be swept and cleaned after each use. The clean-up deposit may not be returned if space is left in an unsatisfactory condition. Please leave the schoolhouse in the same condition as when you first entered the building. * The bathroom may not be used for cleaning dishes. Please plan to clean any dirty dishes, etc. off site. * Parking is limited and the maximum number of people allowed in the Schoolhouse is 50. * The schoolhouse is ADA accessible. * Sorry, no dogs or pets allowed in the building. * Failure to adhere to the above terms may result in the cancellation of use at the County’s discretion.
41. Indemnification
    User agrees to indemnify, release, save and hold harmless San Miguel County and its officials, employees and agents, from and against all liability of loss and against all claims or actions based upon or arising out of damage or injury to persons or property caused by or sustained in connection with the use of the Placerville Schoolhouse. I have read, understand and agree to all the terms stated above for the use of the Placerville Schoolhouse. I understand that this form is only a request for use. I understand that I am responsible for any damages that may occur during my reservation.
43. Signature*

    By typing your name and date above, you are electronically signing the document and agree to abide by the document provisions according to the Uniform Electronic Transactions Act, C.R.S. §24-71.3-101 et seq.

44. Date*
    Date
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field