Contact Information

Please provide a complete address, including street, city, state and zip code.

Event Information

Please enter date of requested usage. MM/DD/YYYY
If other, please specify in comments section below.
If you are submitting this proposal on behalf of any entity other than yourself as an individual, please type your name and position with the organization above. If you are submitting this on behalf of yourself as an individual, please type your name and the word “individually” above. By typing your name and position, you are electronically signing this form on behalf of the organization and representing that you have the authority to submit this form and to bind the organization to the terms stated on this form.
Be sure to select all rooms requested.
if other, please specify in the comments section below.
If yes, please move on to the next question.
If yes, please provide the amount charged per person in the space below.

Insurance Information

Please provide the liability carrier information below.

Hold Harmless Agreement

The organization or individual submitting this request hereby agrees to indemnify, defend, and hold harmless BLaST Intermediate Unit 17, and any director, officer, agent, or employee of BLaST Intermediate Unit 17 against all claims, damages, losses, or penalties that result from the acts or omissions of the employee or agents of the applicant or from the use being made of the facilities.