HomeMy WebLinkAboutGARDEN GROVE UNIFIED SCHOOL DISTRICT (2)City of Santa Ana
Clerk of the Council
AGREEMENT TERMINATION FORM
Please complete this form in its entirety when the attached agreement and all
amendments (if any) are no longer in effect.
Note: If your agreement is grant related, please ensure that all grant retention requirements
have been satisfied prior to signing the termination form.
Is the agreement(s) a permanent record? Yes No
Return form to the Clerk of the Council Office (M-30).
Call 647-1520 if you have any questions.
COTC Office Use Only
OF =1- E COUNCIL
11122 A.14E3: s
The agreement with GQrdm G(ftile uai CA &661 0113 -ICA
N-2022-249
No. was completed on and final payment has been made.
(List all amendments. Use space below if needed.)
Department: ��CS
Phone/Ext.:
Signature:
Date: ( VYs-,
i1agreementslformstlorm - agreement termination form_goldenrod.doc
INSURANCE NOT REQUIRED
S WORK MAY PROCEED GARDEN GROVE UNIFIED SCHOOL DISTRICT
10331 Stanford Avenue, Garden Grove, California 92840
CLERK OF THE COUNCIL APPLICATION AND AGREEMENT
USE OF SCHOOL FACILITIES
N-2022-249
D/ATE'p:A
0: 3�pKY1(TiM��tP) 4M> ALL PERMITS ARE SUBJECT TO SCHOOL SCHEDULE
m l 1 ATTEST: DATE: 08/03/22
Liability Insurance Certificate required in the amount
G of $1,000,000.00 naming Garden Grove Unified School
cd District as additionally insured with endorsement and as Certificate Holder.
ML, Must show Certificate Holder's address as listed above.
O INSURANCE CERTIFICATE EXPIRES:
Vo SCHOOL REQUESTED Rosita Elementary School
V DATES OF USE: 10/01 /22 TO 10/01 /22 HOURS OF USE:
uo
CLERK OF •
CITY OF
3:00 pm TO: 10:00 pm
TYPE OF FACILITY REQUESTED: North & East side parking lots ROOM NUMBERS: NA
SPECIAL SET-UPS: none
PROPOSED USE: extra parking
ATTENDANCE 100
CHARGES: Please note: If custodial time reports received in the Community Services Office reflect additional use time over the
hours of use noted above, you will be billed for the additional coverage on a separate invoice.
Payment for estimated charges is due 10 days in advance of event.
Estimated costs: $a
Comments:
ORGANIZATION:
NAME OF ORGANIZATION City of Santa Ana
AUTHORIZED OFFICER OR AGENT Kristine Ridge
ADDRESS 20 Civic Center Plaza
E-MAIL kridge@santa-ana.org
TELEPHONE (714) 647-5222
CITY Santa Ana ZIP CODE 92702
FACILITIES USER'S DUTY TO INSPECT, WARN AND RECTIFY: Facilities User agrees that the District makes no representations or warranties as to the
condition of the facilities which the User is using and the User agrees to take such property and facilities "AS IS." Facilities User agrees to be responsible for
determining that the facilities are in proper and safe condition to be used for the purpose anticipated; Facilities User agrees to inspect such property before they
are used and to take affirmative steps where necessary to wam users or rectify hazards in order to prevent injury to property and persons. User agrees to refuse
the use of the property if unsatisfactory conditions we not rectified prior to scheduled use.
The applicant hereby agrees, in accordance with California Education Code, Title 1, Part 23, Chapter 4, Article 2, 38134 (i), to hold the Garden Grove Unified
School District, the Board of Education, individual members thereof, and all district employees free and harmless from any loss, damage, cost, claims,
actions/judgments, or expense, regardless of cause, which may arise during or because of such use or occupancy of the school property, facilities, furniture or
equipment. The applicant furthermore certifiesthat the organization shall be personally responsible for any damage or unnecessary abuse of school buildings,
grounds, or equipment while occupied by the organization. The organization agrees to abide by and enforce all rules and regulations of the Garden Grove
Unified School District governing the non -school use of buildings, grounds, and equipment. Furthermore, the undersigned states that, to the best of his
or her knowledge, the school property for use of which application is hereby made will not be used for the commission of any crime or any act that is
prohibited by law. The undersigned further declares that the applicant organization, on whose behalf he/she is applying for the use of school property, upholds
and defends the Constitutions of the United States and the State of California. This statement is made under penalty of perjury.
All applicants are encouraged to preview the District facility prior to reserving to determine appropriateness for the intended activity.
The Board of Education reserves the right to terminate any facility use permits upon written notice by the Board, or its designated representative, to
the person, organization, or group in whose name the facility use permit is issued.
I have read and understand regulations stated above.
Signature of Croup Representative Date
Approved by
9702.100* (OHS Revised 01/13)
District Office Use Only
Date