Please complete all required information. Review the Inclusivity Statement and Facility Use Policy.

Note that Insurance Coverage is Required to use any location of the Facility.

Organization Name

Organization Contact Name

First Name

Last Name

Organization Contact Email

Organization Contact Phone

(###)

###

####

Organization Website

http://

Purpose of Request & Number of People

Date(s) of Request

MM

DD

YYYY

Facility Requested + Additional Details on Request

I have read and understand the Facility Use Policy and agree to the Statement of Inclusion below.

Statement of Inclusion

We believe every kid has what it takes. The mission and core beliefs of Boys & Girls Clubs fuel our commitment to promoting a safe, positive and inclusive environment for all. Boys & Girls Clubs of America supports all youth and teens – of every race, ethnicity, gender, gender expression, sexual orientation, ability, socio-economic status, and religion – in reaching their full potential.

Facility Use policy

Facility Use Request

Statement of Inclusion