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St. Luke's Facility Request Form

First Name * Please enter your First Name

Last Name * Please enter your Last Name

E-mail * Please enter email address/username

Phone Please enter your phone

City

State

Postal Code

Address 1

Address 2

Event Name * Please enter your Event Name

Event Description * Please enter your Event Name

Event Date *

All Day Event

Begin Setup

Start Time *

End Time *

End Teardown

Event Recurrence Rules

Recurrence

Recurrence Rules

Every days(s) *

Every Weekday

Recur Every week(s) on:

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Recur every month(s) on:

Day

The

Recur every years(s)

On

of

Recurrence dates:

End Event after occurrences.

OR

End After Date

Location *

Public?

Public Notes

Public Link

What is the name of your organization? *

Are you a 501 (c) 3 - Not for Profit Organization? *

Yes

No

If Yes, please upload your 501 (c) 3 non-profit status document.

Please include your current Certificate of Liability Insurance Coverage.

Please list the expiration date of that insurance coverage.

Upload signed acknowledgement page of Facility Use Guidelines

Real Person Verification

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