Contact Person: *

First Name

Last Name

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone:

(###)

###

####

Date of Event:

MM

DD

YYYY

Beginning Time:

Hour

Minute

Second

AM PM

End Time:

Hour

Minute

Second

AM PM

I have reviewed the Room Rental Policies:

Yes

No

Room(s) Requested:

Children's Center

Counseling Room

Volunteer Room

Conference Center

Kitchen

Total Hours Requested:

1-4 hours, $25

4-8 hours, $50

8 or more hours, $100