Form DHHS-0004 "Haywood Gymnasium Facility Request Form" - North Carolina

What Is Form DHHS-0004?

This is a legal form that was released by the North Carolina Department of Health and Human Services - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2015;
  • The latest edition provided by the North Carolina Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHHS-0004 by clicking the link below or browse more documents and templates provided by the North Carolina Department of Health and Human Services.

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Download Form DHHS-0004 "Haywood Gymnasium Facility Request Form" - North Carolina

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NC DEPARTMENT OF HEALTH AND HUMAN SERVICES (NC DHHS)
HAYWOOD GYMNASIUM FACILITY REQUEST FORM
Before making a request, please consult the department’s Policy and Procedure Manual, XI-Employee Wellness, Use of Haywood Gym policy, and/or
the NC DHHS Employee Wellness website for this same policy: http://info.dhhs.state.nc.us/olm/manuals/dhs/pol-92/man/HaywoodGym1.htm.
REQUESTOR
FIRST NAME: ________________________________________
LAST NAME: ________________________________________
GROUP INFORMATION (please check one)
DHHS Division/Facility
Other State Agency
Outside Non-Profit Agency
Other
GROUP NAME: ______________________________________________________________________________________________
STREET ADDRESS: __________________________________________________________________________________________
CITY: ___________________________ STATE: ____ ZIP CODE: ________ WEB ADDRESS: ____________________________
PRIMARY CONTACT PERSON INFORMATION
NAME: _____________________________________________________________________________________________________
WORK: ____________________________
CELL: ____________________________ HOME: ____________________________
EMAIL ADDRESS: ___________________________________________________________________________________________
SECONDARY CONTACT PERSON INFORMATION IF PRIMARY CONTACT PERSON IS UNAVAILABLE
NAME: _____________________________________________________________________________________________________
WORK: ____________________________
CELL: ____________________________ HOME: ____________________________
EMAIL ADDRESS: ___________________________________________________________________________________________
REQUESTED USE INFORMATION
EVENT/ACTIVITY DESCRIPTION: _______________________________________________________________________________
DATE(S) REQUESTED: _______________________________________________________________________________________
TIME(S) REQUESTED: ________________________________________________________________________________________
NUMBER OF PARTICIPANTS/OCCUPANCY (approximate): __________________________________________________________
PLEASE READ, SIGN, AND DATE
I (We) assume full responsibility for any damage to NC DHHS equipment and/or property that occurs as a result of the requested use.
Furthermore, I (we) understand that the State of North Carolina, NC DHHS, and their agents, employees, and the sponsors, and those
whose facilities are being used, will not be held liable for any injury or damage which may occur to me, my guests, any participants,
and/or members of the above named group and/or property during the requested use of the Haywood Gymnasium facility.
Signed: _________________________________________
Printed Name:
___________________________________________
Department/Division: ____________________________________________________________________
Date: ____________
Please scan and email this request form to the DHHS Wellness Manager. The Requestor will be notified via email regarding
approval/denial of this request. If approved, the Requestor will need to pick-up an access key card from the front desk
Receptionist of the Adams Building, Blair Drive, Dix Campus, between 8 a.m. and 5 p.m., the day before the event. Key cards
must be returned to the Adams Building, or after hours placed in the drop box at the Dix Campus Maintenance Building
behind the Gym at 805 Whiteside Drive. Please notify Central Regional Maintenance at 919-855-4740 if you return the key card
via the drop box so that they can return it to the front desk Receptionist of the Adams Building.
DHHS-0004, 4/14
Revised 10/2015
NC DEPARTMENT OF HEALTH AND HUMAN SERVICES (NC DHHS)
HAYWOOD GYMNASIUM FACILITY REQUEST FORM
Before making a request, please consult the department’s Policy and Procedure Manual, XI-Employee Wellness, Use of Haywood Gym policy, and/or
the NC DHHS Employee Wellness website for this same policy: http://info.dhhs.state.nc.us/olm/manuals/dhs/pol-92/man/HaywoodGym1.htm.
REQUESTOR
FIRST NAME: ________________________________________
LAST NAME: ________________________________________
GROUP INFORMATION (please check one)
DHHS Division/Facility
Other State Agency
Outside Non-Profit Agency
Other
GROUP NAME: ______________________________________________________________________________________________
STREET ADDRESS: __________________________________________________________________________________________
CITY: ___________________________ STATE: ____ ZIP CODE: ________ WEB ADDRESS: ____________________________
PRIMARY CONTACT PERSON INFORMATION
NAME: _____________________________________________________________________________________________________
WORK: ____________________________
CELL: ____________________________ HOME: ____________________________
EMAIL ADDRESS: ___________________________________________________________________________________________
SECONDARY CONTACT PERSON INFORMATION IF PRIMARY CONTACT PERSON IS UNAVAILABLE
NAME: _____________________________________________________________________________________________________
WORK: ____________________________
CELL: ____________________________ HOME: ____________________________
EMAIL ADDRESS: ___________________________________________________________________________________________
REQUESTED USE INFORMATION
EVENT/ACTIVITY DESCRIPTION: _______________________________________________________________________________
DATE(S) REQUESTED: _______________________________________________________________________________________
TIME(S) REQUESTED: ________________________________________________________________________________________
NUMBER OF PARTICIPANTS/OCCUPANCY (approximate): __________________________________________________________
PLEASE READ, SIGN, AND DATE
I (We) assume full responsibility for any damage to NC DHHS equipment and/or property that occurs as a result of the requested use.
Furthermore, I (we) understand that the State of North Carolina, NC DHHS, and their agents, employees, and the sponsors, and those
whose facilities are being used, will not be held liable for any injury or damage which may occur to me, my guests, any participants,
and/or members of the above named group and/or property during the requested use of the Haywood Gymnasium facility.
Signed: _________________________________________
Printed Name:
___________________________________________
Department/Division: ____________________________________________________________________
Date: ____________
Please scan and email this request form to the DHHS Wellness Manager. The Requestor will be notified via email regarding
approval/denial of this request. If approved, the Requestor will need to pick-up an access key card from the front desk
Receptionist of the Adams Building, Blair Drive, Dix Campus, between 8 a.m. and 5 p.m., the day before the event. Key cards
must be returned to the Adams Building, or after hours placed in the drop box at the Dix Campus Maintenance Building
behind the Gym at 805 Whiteside Drive. Please notify Central Regional Maintenance at 919-855-4740 if you return the key card
via the drop box so that they can return it to the front desk Receptionist of the Adams Building.
DHHS-0004, 4/14
Revised 10/2015