Haverhill Public Schools
Use of Facilities Form
Please Print
| Name of Organization: | HAVERHILL STARS SPECIAL OLYMPICS |
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| Name of Representative: | JAY BARNES |
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| Address: | 1 BLYE RD HAVERHILL |
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| Date Requested: | 9/15/26 |
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| Arrival Time: | 5:45 |
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| Start Time of Event: | 6:00 |
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| End Time of Event: | 8:00 |
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Written in the margin: TUESDAYS 11/17/26 - 3/31/27 SILVER HILL
Please check: ( ) Profit Making Group (✓) Non-Profit Group #____________________
Please check off the location requested and attach list of equipment to be brought into the
facility.
| Gym | #of Classroom(s) | Cafeteria | Auditorium | Library | Fields | Computer Lab |
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| ✓ | | | | | | |
| Expected Number of Participants:# | 60 |
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| Type of Event: | BBALL PRACTICE |
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To be filled out by HPS facilities only
| Item | Base Fee | Hours | Sub Total | Total | Additional Info |
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| Rental Fee | $ 75 | 2 | $ | $ | |
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| Security | $ | | $ | $ | |
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| Custodial | $ Waive | | $ | $ | Custodial staff work 30 minutes before and after event. |
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| Utilities | $ Waive | | $ | $ | |
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| Lighting Panel | $ | | $ | $ | |
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| Cafeteria | $ | | $ | $ | |
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| Subtotal | |
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| Processing Fee | $10.00 |
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| Balance Due | |
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| Signature of Representative | |
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| Date Requested | 9/15/26 |
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| Signature of Principal | |
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Principal Authorization: Approved (✓) Denied ( )
School Committee : Approved ( ) Denied ( )
| HPS FACILITIES | PHONE | WEB |
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| 4 Summer Street, Room 104, Haverhill, MA | 978-374-5725 | haverhill-ps.org |
