Print this form and mail the completed form to
the address below.
ONE ROOM SCHOOL
206 NORTH MERIDIAN STREET
PITTSBORO, INDIANA 46167
FACILITY REQUEST FORM
The One Room School can accommodate a total of 30 students.
Requested Teaching Day____________________________________
(Monday through Friday 9:00AM – 1:30PM. The time can be adjusted
according to the visiting school’s schedule.)
Arrival__________________Departure_________________________
Tours or Presentations at other times – Requested Date______ Time____
School Group or Organization__________________________________
Contact Person______________________________
Phone Number_______________________________
Fax Number___________________________________
Address____________________________________________________
Number of Students Attending__________________________________
(# of girls) (# of boys) (grade level)
Number of Adults Attending___________________________________
(We request that no more than three adult chaperones attend, and that they
participate in the program as older students).
Number of Students with Special Needs ______. Please explain those
needs..____________________________________________________
The One Room School is Handicap Accessible.
ONE ROOM SCHOOL FEES
Make Check Payable to the One Room School Committee
Fee for full teaching day is $85.00
Fee for partial day is $25.00
WAIVER OF LIABILITY
I, __________________ as a representative of__________________ agree to
indemnify and hold harmless, the One Room School Committee and or North West
Hendricks School Corporation for any damage or injury which I or anyone in
this group activity may sustain, in any manner while using the requested
facility. It is further understood that liability insurance will not be
required of this group or individuals granted permission to use said facility,
and that the One Room School and or North West Hendricks School Corporation’s
liability coverage does not cover any group’s or individual’s liability.