Extended Use Application
Permit Number:
(This number will be generated by the Extended Use System after Approval)
v. 2023
1
Please PRINT all information.
Applicants must be familiar with and follow all the rules and regulations contained in Chancellor’s Regulation D-180 governing the use of school buildings. Such
rules and regulations include but are not limited to the following requirements.
The primary use of school buildings is for DOE programs and activities. Secondarily, preference will be given to community, youth and adult group activities.
School buildings cannot be used for the following purposes:
• Personal events (such as birthday parties, weddings, showers, engagement parties)
• Commercial purposes (other than flea markets)
• Gambling
• Political events, activities or meetings including those conducted on behalf of an elected official, candidate, slate of candidates or
political organizations (other than a candidate forum in which all candidates are invited to participate)
Chancellor’s Regulation D-180 prohibits:
• Selling, using, consuming, and/or possessing any alcoholic beverage in any school building
• Selling refreshments unless such sale has been specifically approved on the permit
• Excluding persons for an impermissible discriminatory reason from events or meetings
• Using the school premises as a mailing or business address
• Posting signs, banners, posters or other notices of the permitted activity on school property including, but not limited to, walls, gates, columns, doors,
windows, light standards and trees (other than on indoor or outdoor notice boards only for the purpose of identifying the room where the activity will
be
hel
d)
• Applying the net proceeds from the collection of admission fees or any other collection of money for the benefit of a society, association or organization
of a
religious sect or denomination, or a fraternal, secret or exclusive society or organization (other than veteran organizations and organizations
of
v
olunteer firefighters or ambulance workers)
• Soliciting or accepting tips on school premises
• Advertising related to private, commercial activities
The rules and regulations require that users:
• Ensure that all social, civic, and recreational meetings and entertainment be open to the general public and be non-exclusive.
• Provide at their own cost disability-related reasonable accommodations as needed for individuals with disabilities to participate in the activity to be held
on school grounds. Students may require an adult to administer their medication in order to participate in a User’s program. If the User’s program does
not have access to an on-site medical professional, the User may visit https://www.ecetp.pdp.albany.edu/mat.aspx
to have at least one of its staff
members complete a New York State (NYS) Medication Administration Training (MAT) course approved or administered by the New York City
Department of Health and Mental Hygiene or the State Office of Children and Family Services (OCFS). Information on the NYS MAT Rebate Program
is available at
https://www.ecetp.pdp.albany.edu/matgrant.aspx. The OCFS Guidance on Administering Medication and Compliance with the
Americans with Disabilities Act is available at https://ocfs.ny.gov/main/childcare/mat/matadaguidance.asp.
• Make the following disclaimer on all public notices or on any other material, including media or internet use, that mentions the school name or school
address in connection with the activity to be held on school grounds, and on any signs posted inside or outside the school at the time of the activity
:
“
This activity is not sponsored or endorsed by the New York City Department of Education or the City of New York.” (Except if the activity is sponsor
ed
or
supported by the school, the DOE or the City)
• Pay all contractual costs/fees for using school premises and agree that rates are subject to change by the DOE
• Provide adequate security for the safety and well-being of the attendees
• Exercise the utmost care in the use of school premises and property
• Make good any damage arising from the occupancy of any person on the school premises
• Provide adequate supervision of the activity at all times
• Complete an incident report when safety/criminal incidents occur and return it to the principal and/or the SSA on duty
• Save the DOE harmless from any claim, loss or damage by reason of any act on the part of the applicant, its members, officers, agents or any person
us
ing the premises on the invitation of the applicant.
• Must notify the DOE of any cancellation at least one week prior to the date of the scheduled event (failure to do so will result in a 15% charge of the fee
for
that particular day).
•
To
the
extent
required,
maintain
and
pay
all
premiums
on
a
Commercial
General
Liability
insurance
policy.
The
DOE
has
established
mandatory
insurance
requirements which are set forth in Chancellor’s Regulation D-180, for the following events and activities:
o
Summer
Camps
o Carnivals
o
Flea
Markets
o Boxing, Wrestling and Martial Arts
o Contact Sports, Instruction or Activities
The DOE may require that a User seeking a permit to conduct an activity or event other than that listed above, maintain and pay all premiums on a
Commercial General Liability insurance policy with a limit of not less than $1,000,000 per occurrence. Such policy must list the DOE and the City of New
York, including their respective officials and employees, as additional insureds. The organization applying for the permit must inform its insurance broker that
such additional insured coverage is to comply with Insurance Services Office (ISO) Form CG 20 26, a standard insurance industry-wide form. Prior to and as
a condition to any event, the User shall provide a certificate of insurance evidencing such insurance to the principal.
Extended Use Application
Permit Number:
(This number will be generated by the Extended Use System after Approval)
v. 2023
2
I.
Organization Information: To be completed by the applicant.
Name of Applicant/Org: Tax ID #:
Address: City: State: Zip Code:
E-mail: And/or Fax #: Phone:
Name of Authorized Representative: Title of Rep:
Permit Period (mm/dd/yyyy) From: To:
Description of Activities to be conducted: Nature of Event: _
Name of Activities Supervisor: Anticipated Attendance: Liability Insurance: ☐Yes ☐No
Special Requests (check all that apply)
☐ Swimming Pool (If checked) Name of Teacher: Red Cross Water License:
☐ Shop Rooms (If checked) Name of Teacher: License:
☐ Home Eco Rooms (If checked) Name of Teacher: License:
☐ Admission Fee (If checked) Amount and Beneficiary: Amount:
Beneficiary Address:
Phone #:
Email:
☐ Sale of Goods (If checked) Type of Item:
☐ NYPDSSD Coverage
☐ Stage Scenery
☐ School Personnel Required
☐ Donations
Certification of Applicant
• I hereby certify that the information I have provided on the form is complete and accurate to the best of my knowledge.
• I hereby certify that the activities to be conducted in the school premises do not include any of the prohibited uses described
above or in Chancellor’s Regulation D-180.
• I understand and agree to observe all the rules and regulations summarized above and contained in Chancellor’s Regulati
on
D-1
80 and in this application and to comply with all applicable New York State laws and regulations governing the extended
use of school buildings.
• I understand and agree that the failure to do so may lead to the cancellation of the permit, the denial of future permit
applications, or other legal action by the DOE.
• I understand and agree that the DOE, in light of the inherent risk of injury to participants, may in its sole discretion, decli
ne
per
mission for any event.
• I understand and agree that the DOE may terminate any permit at any time when it is in the best interest of the DOE.
Signature of Applicant/Representative: Date:
Extended Use Application
Permit Number:
(This number will be generated by the Extended Use System after Approval)
v. 2023
3
II.
Permit Detail Information: To be completed by custodian and applicant. Please affix additional
copies of
this section to this permit application if you require additional permit details.
Boro/School: School Email: District:
School Mailing Address: City: , NY Zip:
Name of Custodian Engineer: Phone: Email:
Permit Details
Days of Week (check all that apply): Date From (mm/dd/yyyy): Date To (mm/dd/yyyy):
☐ Mon ☐Tue ☐Wed ☐Thu ☐Fri ☐Sat ☐Sun Time From: ☐ am ☐pm Time To: ☐am ☐pm
Space Usage
Space Description
Quantity
Cost
Athletic Field
$12
Auditorium, H.S.
$12
Auditorium, J.H.S.
$12
Baths, 5 or more heads
$12
Baths, less than 5 heads
$12
Bleachers
$12
Cafeteria
$12
Classrooms/Teacher Rooms
$2
Furniture Moved
$2
Gyms
$12
Locker Rooms (4 or more)
$12
Locker Rooms (1-3)
$12
Special Rooms
$2
Swimming Pools
$40
Special Services
Hours
Straight
Time and 1/2
Service Description
Yes
No
Breakfast
Shop Mechanics
Cafeteria Cleanup - Elem.
Cafeteria Cleanup - J.H.S.
Cafeteria Cleanup - H.S.
III.
Permit Cost
Total # of Permit Details: _ Grand Total: $ _
(All permit details)
VI.
Custodian’s Confirmation of Availability of Space
☐
Take the Field Waiver Approved ☐ Total # of Permit Details
Name (Print):
Signature:
VII.
Principal's Authorization
Name (Print):
Signature:
Date:
Extended Use Application
Permit Number:
(This number will be generated by the Extended Use System after Approval)
v. 2023
4
Supplemental Information
The Permit Detail Information sections below are to be completed if additional Permit Detail space is required to complete your permit application. Fill out as many
sections as you require, and affix the pages to the original application.
Boro/School: _ _ _ _ _ School Email: __ __ _ __________ _ _ District: _ _
School Mailing Address: _ _ _ __ _ City: __ _ _________________ _ , NY Zip: _ Name of Custodian
Engineer: _ _ Phone: ____________________________ Email: _
Permit Details
Days of Week (check all that apply): Date From (mm/dd/yyyy): Date To (mm/dd/yyyy):
☐ Mon ☐Tue ☐Wed ☐Thu ☐Fri ☐Sat ☐Sun Time From: ☐ am ☐pm Time To: ☐am ☐pm
Space Usage
Space Description
Quantity
Cost
Athletic Field
$12
Auditorium, H.S.
$12
Auditorium, J.H.S.
$12
Baths, 5 or more heads
$12
Baths, less than 5 heads
$12
Bleachers
$12
Cafeteria
$12
Classrooms/Teacher Rooms
$2
Furniture Moved
$2
Gyms
$12
Locker Rooms (4 or more)
$12
Locker Rooms (1-3)
$12
Special Rooms
$2
Swimming Pools
$40
Special Services
Service Description
Hours
Straight
Time and 1/2
Cleaner
Fireman/Handyman (Local 47)
Fireman (Local 94)
Stationary Engineer
Watchman
Pool Showers
Service Description
Yes
No
Breakfast
Shop Mechanics
Cafeteria Cleanup - Elem.
Cafeteria Cleanup - J.H.S.
Cafeteria Cleanup - H.S.
Permit Details
Days of Week (check all that apply): Date From (mm/dd/yyyy):
Date To (mm/dd/yyyy):
☐ Mon ☐Tue ☐Wed ☐Thu ☐Fri ☐Sat ☐Sun Time From: ☐ am ☐pm Time To: ☐am ☐pm
Space Usage
Space Description
Quantity
Cost
Athletic Field
$12
Auditorium, H.S.
$12
Auditorium, J.H.S.
$12
Baths, 5 or more heads
$12
Baths, less than 5 heads
$12
Bleachers
$12
Cafeteria
$12
Classrooms/Teacher Rooms
$2
Furniture Moved
$2
Gyms
$12
Locker Rooms (4 or more)
$12
Locker Rooms (1-3)
$12
Special Rooms
$2
Swimming Pools
$40
Special Services
Service Description
Hours
Straight
Time and 1/2
Cleaner
Fireman/Handyman (Local 47)
Fireman (Local 94)
Stationary Engineer
Watchman
Pool Showers
Service Description
Yes
No
Breakfast
Shop Mechanics
Cafeteria Cleanup - Elem.
Cafeteria Cleanup - J.H.S.
Cafeteria Cleanup - H.S.
Extended Use Application
Permit Number:
(This number will be generated by the Extended Use System after Approval)
v. 2023
5
Permit Details
Days of Week (check all that apply): Date From (mm/dd/yyyy):
Date To (mm/dd/yyyy):
☐ Mon ☐Tue ☐Wed ☐Thu ☐Fri ☐Sat ☐Sun Time From: ☐ am ☐pm Time To: ☐am ☐pm
Space Usage
Space Description
Quantity
Cost
Athletic Field
$12
Auditorium, H.S.
$12
Auditorium, J.H.S.
$12
Baths, 5 or more heads
$12
Baths, less than 5 heads
$12
Bleachers
$12
Cafeteria
$12
Classrooms/Teacher Rooms
$2
Furniture Moved
$2
Gyms
$12
Locker Rooms (4 or more)
$12
Locker Rooms (1-3)
$12
Special Rooms
$2
Swimming Pools
$40
Special Services
Hours
Straight
Time and 1/2
Service Description
Yes
No
Breakfast
Shop Mechanics
Cafeteria Cleanup - Elem.
Cafeteria Cleanup - J.H.S.
Cafeteria Cleanup - H.S.
Permit Details
Days of Week (check all that apply): Date From (mm/dd/yyyy): Date To (mm/dd/yyyy):
☐ Mon ☐Tue ☐Wed ☐Thu ☐Fri ☐Sat ☐Sun Time From: ☐ am ☐pm Time To: ☐am ☐pm
Space Usage
Space Description
Quantity
Cost
Athletic Field
$12
Auditorium, H.S.
$12
Auditorium, J.H.S.
$12
Baths, 5 or more heads
$12
Baths, less than 5 heads
$12
Bleachers
$12
Cafeteria
$12
Classrooms/Teacher Rooms
$2
Furniture Moved
$2
Gyms
$12
Locker Rooms (4 or more)
$12
Locker Rooms (1-3)
$12
Special Rooms
$2
Swimming Pools
$40
Special Services
Service Description
Hours
Straight
Time and 1/2
Cleaner
Fireman/Handyman (Local 47)
Fireman (Local 94)
Stationary Engineer
Watchman
Pool Showers
Service Description
Yes
No
Breakfast
Shop Mechanics
Cafeteria Cleanup - Elem.
Cafeteria Cleanup - J.H.S.
Cafeteria Cleanup - H.S.