DATE AND TIME REQUESTED:

Starting Date __________________________ Starting Time _____________________

Set-up Time ____________to____________

Ending Time ____________________   (specify times to the half hour)

Subsequent dates: (circle one)

   None (one time only)

   Daily:     weekdays    or   every day       until _______________  (ending date)

   Weekly:      the same day of week every ________________ week(s)   until _______________ (ending date)

   Monthly:     the same day of month every _______________ month(s) until _______________ (ending date)

   The ___________  same-day-of-week of every ____________ month(s)  until _______________ (ending date)

Except (dates to skip): ___________________________________________________________

DESCRIPTION OF USAGE:

Event or activity ____________________________________________________________________________________

Usage Topic (circle one):

1.  Parish religious education                 5.  Parishioner event                               9.  Non-parishioner event

2.  Parish administration                          6.  Community even                             10.  Other __________________________

3.  Parish ministries etc.                           7.  Parish fundraiser                                               __________________________

4.  Parish social event                              8.  Fundraiser for other organizations

Number of attendees  _____________            Will alcoholic beverages be brought in? ___________

Will food be served? _____________   If yes, name of caterer ___________________________________

Will there be money transactions on the premises (admission fees, sales, etc.)? ______________________

Set-up Needs (e.g., seating at tables, theater-style seating, refreshment tables, dance floor, bar, stage, a/v equipment, etc.)

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

REQUESTED BY:

Name _______________________________________  Organization ________________________________________

Address ________________________________________________________________________________________

Telephone __________________________ Fax __________________________ Cell ___________________________

E-mail _________________________________________  Web Address _____________________________________

       Please Circle All that Apply:    Parishioner     Non-profit     Non-parishioner     For-profit 

I have read the Terms & Conditions for Rental of the Saint Michael Parish Center, agree to comply with all aspects of it and

       this agreement, and accept responsibility for compliance:

___________________________________________________ (signature), _____________________________ (date)

       Return this request with deposit or payment in full to St. Michael Parish, 90 Concord Road, Bedford, MA 01730

OFFICE USE ONLY:

Request received on ______________    Deposit amount $________________  Date $  received _________________

Room(s) assigned ________________   Full Rental Fee: $ ________________  Date $  received _________________