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2. Organization Name*
4. Mailing Address*
6. City*
7. State*
8. Zip Code*
10. Contact Person*
11. Phone*
13. Email Address*
15. Will you be the person checking in for the meeting?*

    1. Yes
    2. No
16. Do you have a Kearney Public Library card?

    1. Yes
    2. No
18. Getting a library card
    http://cityofkearney.org/1603/Apply-for-a-library-card

    We do ask that you register for a Kearney Public Library card prior to the meeting. They are free. All we require is a valid driver's license and something with the current address (if your ID does not show it). Please come a few minutes before your meeting and our staff will be happy to assist you with this or visit the link above to apply online and pick up your card on the day of your meeting.
20. Check-In Representative
21. Check-In Representative Phone
23. Check-In Representative Email Address
24. Does the check-in representative have a Kearney Public Library card?

    1. Yes
    2. No
26. Is there another check-in representative?*

    1. Yes
    2. No
27. Alternate Check-In Representative
29. Alternate Representative Phone
30. Alternate Representative Email Address
32. Getting a library card
    http://cityofkearney.org/1603/Apply-for-a-library-card

    We ask that the check-in representative registers for a free Kearney Public Library card prior to the meeting. All we require is a valid driver's license and something with the current address (if their ID does not show it). They may come a few minutes before the meeting and staff will assist them or visit the link above to apply online and pick up the card on the day of the meeting.
34. Meeting Topic*
36. Expected Number of Attendees*
37. Are you a non-profit organization?*

    1. Yes
    2. No
39. Requested Date of Meeting*
    Requested Date of Meeting
40. Requested Time*
    Requested Time Start Time

    —

    Requested Time End Time
    Please include set-up and tear-down time in your request.
41. Would you like to request multiple meeting dates?

    1. Yes
    2. No
43. Please list the additional dates/times you'd like to request meetings.
45. Available amenities:*

    1. Extra tables / chairs
    2. Wi-Fi
    3. Projector / screen
    4. Computer
    5. VGA/HDMI laptop connection
    6. Wireless connection (Windows 10 & iOS)
    7. Microphone
    8. Portable hearing loop
    9. Portable speakers
    10. Extension Cords / Power Strips
    11. Conference call phone
    12. Webcam
    13. Dry erase board
    14. Podium
    15. Easel
    16. Coffee pot / filters (you supply coffee)
    17. None
46. Items you will provide:*

    1. Food
    2. Laptop
    3. Projector
    4. None
47. Policy Agreement*

    1. Agree
    2. Disagree

    As an authorized adult representative of the above organization, by selecting "agree," I hereby apply for the use of the meeting room as indicated above. I have read the policies and rules governing the use of the meeting room facilities and agree that they will be carefully observed. If a meeting is canceled, I agree to notify the library as far in advance as possible.
49. Please Note: A confirmation email will be sent once the meeting is approved.
51. FOR LIBRARY USE ONLY
53. Application Approved by:
54. Date Approved:
56. Assigned Room:
    Loup / North Platte / South Platte / Niobrara
57. Contact Signature:
59. Deposit Paid
    Cash Check
60. Deposit Returned
    Yes / No / Donated
61. Contact Initials
63. Library Staff Initials
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit

* indicates a required field