Shiloh Baptist Church Rental Facility Application Form

2. Please complete the form below. Upon completion, you will receive an email notification of your status within 48 hours.

4. Name of Organization

6. Name*

   First Name

7. first*

   Last Name

9. Street Address

10. City, State & Zip

12. Home Phone

13. Work Phone

15. Email

17. Date of Meeting*

18. Is this a recurring meeting?

    1. Yes
    2. No

19. If recurring, please list the dates below.

21. Set - up Time

22. Event Time

23. Clean-up Time

25. Location Requested

    1. Executive Office (1429 Duke Street)
    2. Historic Sanctuary (1401 Duke Street)
    3. Fellowship Hall (1401 Duke Street)
    4. Worship Center (1401 Jamieson Avenue)

26. Type of Room Request

    1. Small Room (up to 15)
    2. Medium Room (16-35)
    3. Large Room (36-90)
    4. Worship Center (500)
    5. Worship Center- small room (up to 15)
    6. Historic Sanctuary (300)
    7. Fellowship Hall

28. Standard Room Set - up

    1. Boardroom
    2. Theater
    3. U-shape
    4. Other

29. If other, please explain.

30. Basic equipment can be supplied for your meeting. Please select the items you may need for the meeting.

    1. Audio Visual
    2. Laptop
    3. Projector
    4. Projector Screen
    5. Easel with paper and markers
    6. Other

    Please select all that apply.

32. Will fees be collected?

    1. Yes
    2. No

33. If yes, indicate method.

    1. Onsite
    2. In advance
    3. Both

34. Is food being served?

    1. Yes
    2. No

36. Does your organization have Liability Insurance?

    1. Yes
    2. No

37. Select organization status.

    1. Not For Profit
    2. For Profit
    3. City Residence
    4. Civic Group

39. Purpose of the event*

40. Event Title

42. Estimated Attendance

43. Target Audience

    1. Pre - Teen (0-12)
    2. Teen/Young Adult (13-21)
    3. Adults (22 59)
    4. Senior Adult (60 & older)

44. Is event/activity

    1. Open to the public
    2. Private (invitation only)
    3. Other

46. SPECIAL CONSIDERATION: The undersigned certified that he/she has read and understands the rules and regulations and responsibilities of the renters of Shiloh facilities and equipment, and that the same will be enforced and honored by the renting organization. The undersigned further certifies that he /she is a legally authorized representative to act for and accept such responsibilities for the organization. Final approval of this application is contingent on receipt of deposit. Cancellation made less than 14 days in advance of the rental date may result in fortfeiture of deposit. I do hereby release, forever discharge and agree to hold harmless Shiloh Baptist Church and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may incurred by the undersigned and the participant(s) that may occur while said person is participating in the above-described activity. The undersigned further hereby agrees to hold harmless and indemnify SBC, it’s directors, employees and agents for any liability sustained by said acts of said participant, including expenses incurred attendant thereto.

48. Electronic Signature

    Enter your name

49. Date

51. A nonrefundable deposit of $25, must be made when the application is turned in which will also hold the reservation. No rental is secured without the deposit/full donation. The balance of the fee must be paid in full no longer than 14 days prior to the event. Full payment is due at time of application if it is shorter than 30 days prior to the event. Donations are made payable to Shiloh Baptist Church.
    Checks can also be mailed to Shiloh Baptist Church Facility Rental 1429 Duke Street, Alexandria, VA 22314

    Checks can also be mailed to Shiloh Baptist Church Facility Rental 1429 Duke Street, Alexandria, VA 22314

Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field