Our Lady of Lourdes Parish and St Joseph Mission Church
20 River Rd.
Pittsfield N.H. 03263
(603) 435-6242
APPLICATION FOR USE OF PARISH FACILITIES
To:  Pastor’s Office
Received From:___________________________________________Date:__________________
Received by: _____________________________________________Date__________________
Name/Organization______________________________________________________________
Address________________________________________________________________________
Sponsor/Contact Name___________________________________________________________
Telephone_______________________________________Cell____________________________
Date(s) Requested_______________________________________________________________
Hours________________________________ Set Up     Yes____________ No_______________
Set Up Arrangements (Describe on reverse side) Date__________________________________
Facility Requested________________________________________________________________
Description of Activity_____________________________________________________________
Certificate of Insurance Attached        Yes________ No________
Hold Harmless Agreement Approved by Parish Council           Yes__________ No___________
General Public Invited              Yes___________ No_________
Requirements:  Chairs (#)__________ Tables (#)_____________ Other____________
Were Police and Fire Departments Notified     Yes_____________ No_____________(Users must make own arrangements for police and fire coverage and payment.)
Key #_____ Received by _______________________ Date_______________For______________                                                                                                                                          (facility)
Key #_____Returned on Date__________________           
I understand that if I lose or misplace this key that I will be held responsible for the re-keying of the door.  The key must be returned to the rectory on the first business day following the event.   There shall be NO USE OF CONTROLLED SUBSTANCES ON CHURCH PROPERTY AT ANY TIME, NO TOBACCO USE IN PARISH BUILDINGS AND NO USE OF ALCOHOLIC BEVERAGES UNLESS NOTED AND STATED IN THE APPLICATION.   Strict enforcement of these regulations shall be the responsibility of the renter/user.
I/We hereby agree to abide by all rules and regulations regarding the use of the facility, which I/WE have read and understand, agree to pay the fees stipulated and agree to reimburse OUR LADY OF LOURDES & ST. JOSEPH PARISH for any damage done.  I/WE further understand that failure to do so may result in denial of future use.
Signed__________________________________________________ Date_______________________