Event Date*

mm/dd/yyyy

EVENT NAME*

Description of Event*

Event START & END Time?*

Requested UNLOCK time?*

Requested LOCK-UP time?*

Location/Room(s)*Check all that apply

Sanctuary

WGS Hall (gym)

Kitchen

Board Room

Pathfinder Room

Youth Room

WOW Room

Spanish Chapel

Japanese Chapel

Beginners Room

Kindergarten Room

Primary Room

Department hosting event?*

Event Contact Person*

First

Last

Event Contact Person's Email*

Event Contact Person's Phone Number*

Tables needed?*

Yes

No

Quantity of Tables needed?*

Sound equipment needed?*

Yes

No

Sound equipment description?*

Visual equipment needed?*

Yes

No

Visual equipment requested? (ie: PowerPoint, DVD...)*

Other notes...

Authorized by: (entering name here is same as signature)*

Signature Date*

mm/dd/yyyy

Westminster Good Samaritan

Facility Usage Request Form