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CITY OF COLTON <br />PARKS, RECREATION, & FAMILY SERVICES <br />FACILITY USE APPLICATION AND AGREEMENT <br />(909)370-6153 <br />REQUEST FOR USE OF _ <br />(DATES) <br />FACILITIES AND EQUIPMENT REQUESTED <br />❑ Main Room ❑ Tables # <br />❑ Dance Room ❑ Chairs # <br />❑ Activity Room ❑ Pool <br />C3 Meeting Room NOTE: PLEASE SUBMIT DIAGRAM <br />g OF SET-UP REQUESTED AT <br />❑ Kitchen LEAST 48 HOURS PRIOR TO <br />❑ Game Room SCHEDULED USE. <br />❑ Baseball Diamond <br />❑ Field Lights — Time <br />❑ Snack Bar — Time <br />❑ Fleming Park (Must be approved by Council) <br />❑ Stage <br />SET UP TIME <br />(include set-up / clean-up time) <br />Set up Time: From: IV 41y To: <br />Program Time: From: 1,2444 To: <br />Clean Up Time: From: I To: pptvty <br />Purpose of Activity <br />Expected Attendance: Adults <br />Youths /dJ <br /># of Colton Residents <br />Is Activity Open to the Public:. Yes IX No <br />Will Admission Be Charged: Yes No <br />Will Donations Be Accepted: Yes No <br />If yes, what will the proceeds be used for? <br />DEPT. U Y <br />Received. J <br />I itials <br />Date/Time J_ . 'I <br />Processed J/4' /'_)� <br />Dae ! Thitial <br />Calendar <br />Date / Initial <br />We hereby certify that we shall be personally responsible, on <br />behalf of our organization for any damage or unnecessary abuse <br />of buildings, grounds or equipment throughout the use of said <br />premises by our organization. <br />WE AGREE TO ABIDE BY AND ENFORCE THE RULES <br />AND REGULATIONS OF THE CITY OF COLTON AND <br />CERTIFY THAT WE HAVE READ THE RULES AND <br />REGULATIONS ON THE BACK OF THIS APPLICATION. <br />We also received a copy of the Independent Contract <br />Agreement. Yes No k <br />Ins. <br />Initials - H. H. A. Will pr oc s Ins.Proc. <br />Name of Organization <br />Name (please nt) �" « 6451—' N&4 -4 elk. <br />Signature A <br />Contact Person (cry Event L-��tJi� i����/�,d� Y%• <br />Title Qi�}G!N/Zc%L <br />Address <br />City, Zip Code fo ',el 11�i�iAC/ <br />Phone (daytime) 96'29� - 0& 36J a <br />Phone (evening) <br />Date of application _ ['J , 20 0 <br />Application For Facility Use Is: Charges <br />Fleming Park: Council Approved Denied Deposit <br />Facility Approved Denied Ballfield <br />By FAniliiV <br />Name of Customer Called <br />By Whom Date <br />Approval Is Subject To Conditions Listed On Back <br />Staff Assigned <br />Date Staff Assigned Time Staff Assigned <br />Assigned by (Supervisor) <br />Keys picked up: <br />Staff Member <br />Remarks: <br />Amount <br />VCR/TV <br />Pool <br />Kitchen <br />Amount <br />Cost of Staff <br />I Gym <br />Cost of Lights <br />Insurance <br />PAS stem <br />Other <br />Stale <br />Other <br />Actual Expense (both columns) = <br />Amount Charged to Applicant = <br />Date Paid 120 Initials <br />Date Proc'd , 20 Initials <br />Fax Notification: Public Works: Risk (Ins.) PD Fire Elec. <br />Date Date Date Date Date Date <br />Rcvd Apprvl Inst. Public Works: Risk (Ins.) PD Fire Elec. <br />Date Date Date Date Date Date <br />12/05/00 <br />Facility Use App. <br />