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REQUEST FOR USE OF <br />(DATES) <br />CITY OF COLTON <br />NEIGHBORHOOD SERVICES DEPARTMENT <br />FACILITY USE APPLICATION AND AGREEMENT <br />370-6153 <br />FACILITIES AND EQUIPMENT REQUESTED <br />❑ Main Room ❑ Tables # <br />❑ Dance Room ❑ Chairs # <br />❑ Activity Room ❑ Pool <br />❑ Meeting Room PLEASE SUBMIT DIAGRAM <br />OF SET-UP REQUESTED AT <br />❑ Kitchen LEAST 48 HOURS PRIOR <br />TO SCHEDULED USE. <br />❑ Game Room <br />❑ Baseball Diamond <br />❑ - Field Lights - Time <br />❑ - Snack Bar - Time <br />TIME OF USE <br />FROM �'Nil A.M., <br />TO 11 1 0D A.M., <br />1. urp se of Acti <br />2. ExpectQ ed Attendance: Adults <br />Youths <br />3. Is Activity Open to the Public: <br />Yes No <br />4. Will Admission Be Charged: <br />Yes No �C <br />5. Will Donations Be Accepted' <br />Yes No <br />If yes, what will the proceeds be used for? <br />Application For Facility Use Is: <br />K -a-&4 0:00t4 <br />We hereby certify that we shall be personally responsible, <br />on behalf of our organization for any damage or <br />unnecessary abuse of buildings, grounds or equipment <br />through the use of said premises by our organization. <br />WE AGREE TO BY AND ENFORCERULES AND <br />REGULATIONS FBTHE CITY OF COL ON A DHCERTIFY THAT <br />WE F RE RULES AND REGULATIONS ON THE <br />BACK OAPPLICATION. <br />of Organization I f l(d fll <br />Ii vM A 1 A <br />Name (pleasnprint) <br />A. - <br />tow <br />Date . <br />FOR DEPARTMENT USE ONLY <br />Approved Denied <br />By X <br />Approval Is Subject o Conditions Listed On Back <br />Deposit <br />Fee <br />Staff Assigned <br />Date Staff Assigned Time Staff Assigned <br />Assigned by (Supervisor) <br />Keys picked up: «t ember <br />Remarks <br />Date Paid '19— <br />Date <br />t8Date Processed -,19 <br />White - Office Canary - Permittee - Pink - Facility - Goldenrod - Public Works <br />5197 <br />