7500 - Electronic Key Access Request Agreement
Electronic Key Request Form
This form is for community members who would like to use school facilities during non-school hours. Uses of school facilities are limited to those explained in district policy #7500 Building Use & Security. Any misuse of school facilities will result in access being revoked. Electronic keys are issued only to adults. School-aged children (Including 18 year-old seniors that have not yet graduated) are not permitted to use school facilities without adult supervision.
Date of Request: ________________
Purpose: ___________________________________________
School(s) for which access is being requested:
- Piute High School
- Circleville Elementary School
- Oscarson Elementary School
Please provide the names and contact information for every adult that may use the electronic key. Only adults of the same household should be included. Adults from different households should make a separate request for building access. Write an “X” or check mark by the name that will be the Primary Contact (PC) for the electronic key.
|
PC |
Full Name |
Phone Number |
E-Mail Address |
Address |
If more than three adults from your household may need access, include their names and contact information on the back.
By signing below, the primary contact agrees to all the terms and conditions of the school district building use policy. The primary contact is also responsible for ensuring the other household adults listed will follow the guidelines of the district building use policy. Violation of these guidelines will result in school access being denied.
______ (PC Initial) I will not allow children under 18 or students to use this key without an adult listed above.
______ (PC Initial) I will ensure the building is left clean and undamaged.
______ (PC Initial) I will not allow children to roam the school(s) unsupervised.
______ (PC Initial) I will ensure that lights have been turned out when leaving the school.
______ (PC Initial) I will not leave blocks in school doors.
Signature of Primary Contact_______________________________________
Only principal signatures for which building access is being requested are required. Principal signatures must be obtained by the primary contact in person.
Signature of Piute High School Principal___________________________________
Signature of Circleville Elementary School Principal___________________________________
Signature of Oscarson Elementary School Principal___________________________________
When all signatures needed are collected, this form should be returned to the school district office with a payment of $50. The primary contact will be billed $30 annually until the electronic key is returned to the district office.