205 Rumely Street LaPorte, IN 46350
Phone: 219-362-7145 Fax: 219-362-1358

Facility Use Application

* All fields are required

*Building Requested:
*Facility or Field Requested:
*Date(s) Requested:
*Time Requested: From: To:
  (Doors will be open 30 minutes before and after these times.)
*Estimated Number in Attendance
*Purpose of Rental:
(Limit 500 Characters) 
*Equipment Items Requested:
(Limit 500 Characters) 
*Set-Up Requested:
(Limit 500 Characters) 
Other Information:
*Name of Supervisor in Charge at Rental:
*Entrance Fees Charged?: Amount:
*In District Group?: Percent of Local Residents:

*NAME OF ORGANIZATION:
*ADDRESS:
*YOUR NAME: *WORK PHONE:
*YOUR EMAIL: *HOME PHONE:
* 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.