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Requester's Full Name*

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Requester's Phone #*

Dua-ash-Shifa requested for*

Reason

Requester's Full Name*

Requester's Street Address*

Requester's City*

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Date of Event*

Time of Event*

Number of Guests*

Purpose of Use*

Facility Use Guidelines:
NO staples and/or glue of any kind can be applied on the walls.
All furniture moved must be returned to the original setting at the end of their use.
You will bring your own supplies for use – e.g. Plates, Napkins, Cups, Trash Bags, Spoons/Forks, and so on.
Any trash accumulated during the facility's use must be bagged and disposed off in our trash bin (outside) prior to leaving the facility.
All posted Parking Rules must be observed.
All lights, AC/Heater and/or all Audio/Video Equipment must be turned off.
All doors must be closed when leaving the facility.

In addition to the $150 rent, there is a $50 refundable deposit – if the facility is returned in its original satisfactory condition.

Consent*
"I understand and agree to the above guidelines. I take full responsibility for any and all damages that may result from use of the facilities which shall include but is not limited to extra custodial charges and possible repair/replacement costs."