Senior Room Rental Form

1. Do not consider this room reserved until formal confirmation is received. Staff will follow up with confirmation, fees, and damage deposit.

   Do not consider this room reserved until formal confirmation is received. Staff will follow up with confirmation, fees, and damage deposit.

2. Today's Date:*

3. Date Needed:*

4. First Name*

5. Last Name*

6. Availability - Mon-Fri: 5-10pm; Sat: 8am-10pm; Sun: 1-10pm

   Availability - Mon-Fri: 5-10pm; Sat: 8am-10pm; Sun: 1-10pm

7. Start Time*

8. End Time*

9. Equipment needed
   1. Kitchen
   2. Tables
   3. Chairs

10. Group Name*

11. Contact Person*

12. Address1*

13. City*

14. State*

15. Zip*

16. Home Phone*

17. Work Phone

18. Email Address*

19. Expected Attendance*

20. Purpose of Rental*

21. Rules, Regulation and Policies for Room Rental
    Policies for Room Rental

22. Agree with Policies*
    1. Yes
    2. No

23. I have read the policies for the room rental. I fully agree and accept all responsibilty for the terms and conditions of this agreement.

    I have read the policies for the room rental. I fully agree and accept all responsibilty for the terms and conditions of this agreement.

Leave This Blank:


24. 1. Receive email copy
25. Email address

26. Submit Submit and Print

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