205 Rumely Street La Porte, IN 46350
Phone: (219) 362-7145
Fax: (219) 362-1358
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Facility Use Application

All fields marked with an asterisk (*) are required

*Building Requested: *Select a building.Please select an item.
*Facility or Field Requested: *Select facility.*Select facility.
*Date(s) Requested: *Enter date(s).
*Time Requested: From: *Enter start time. To: *Enter end time.
  (Doors will be open 30 minutes before and after these times.)
*Estimated Number in Attendance *Required
*Purpose of Rental:
(Limit 500 Characters) 
*RequiredCharacter limit reached.
*Equipment Items Requested:
(Limit 500 Characters) 
*RequiredCharacter limit reached.
*Set-Up Requested:
(Limit 500 Characters) 
*RequiredCharacter limit reached.
Other Information:
*Name of Supervisor in Charge at Rental: *Required
*Entrance Fees Charged?: Amount:
*In District Group?: Percent of Local Residents:

*NAME OF ORGANIZATION: *Required
*ADDRESS: *Required
*YOUR NAME: *Required *WORK PHONE: *Required
*YOUR EMAIL: *RequiredInvalid format. *HOME PHONE: *Required
Please make a selection. * By checking this box, I confirm that I have read and understand the Terms and Conditions
for Facility Rentals
and will abide by the requirements including indemnification of LPCSC.
 
*Please note that this is only an appplication for rental, not a reservation.