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CITY OF COLTON NEIGHBORHOOD SERVICE DIVISION FACILITY USE APPLICATION AND AGREEMENT (909)370-6153 REQUEST FOR USE OF _ Eli ml I (DATES) NLV DEPT. USE ONLY Received. Initials Date / Time Processed Date / Initial Calendar Date / Initial FACILITIES AND EQUIPMENT REQUESTED We hereby certify that we shall be personally responsible, on • oom O Tables # behalf of our organization for any damage or unnecessary abuse O Chairs # of buildings, grounds or equipment throughout the use of said • Dance Rom Q Pool premises by our organization. 0 Activity Room 0 Meeting Room NOTE: PLEASE SUBMIT DIAGRAM g OF SET-UP REQUESTED AT WE AGREE TO ABIDE BY AND ENFORCE THE RULES 0 Kitchen LEAST 48 HOURS PRIOR TO 0 Game Room SCHEDULED USE. AND REGULATIONS OF THE CITY OF COLTON AND Q Baseball Diamond CERTIFY THAT WE HAVE READ THE RULES AND 0 Field Lights - Time REGULATIONS ON THE BACK OF THIS APPLICATION. O Snack Bar - Time We also received a copy of the Independent Contract Fleming Park (Must be approved by Cour;cil) Ie 1 f in A k Agreement. Yes No Ins. Stage it F'7r CI f y Initials - H. H. A. Will process Im.Proc. TIME OF USE Name of Organization (include set-up / clean-up time) FROM (0.30 Q m• J � � (.�i/ t o Irch & i d f) iiof Name (please print) 1 TO .00 Purpose of Activity Chu d'''SMI&ODMmunt you t04 Signature Al, eeA Expected Attendance: Adults -700 Contact Person @ Event e r_ Youths 30 Title Se n I @ S r # of Colton Residents 5700 �' '�,,11f Address D_ W,PS "F S f t1i Is Activity Open to the Public: Yes No J1 City, Zip Code Yi •3 P Will Admission Be Charged: Yes No K Phone (daytime)NQ� ga's-3% 7 Will Donations Be Accepted: Yes No Phone (evening) SQ M t If yes, what will the proceeds be used for? W f, Will q��-1 Date of application �g�t��8 �ana'�ior1��}'orrt Dur norlma/ FOR DEPARTMENT USE ONLY plication For Facility We Is: Charges Amount Charges Amount Fleming Park. Council.4pproved Denied Deposit VCR / TV Facility Approved Denied Ballfield Pool BY Facility Kitchen Name of Customer Called Cost of Staff Gym By Whom Date Cost of Lights Insurance Approval Is Subject To Conditions Listed On Back PA System Other Staff Assigned Date Slaff Assigned Time Staff Assigned Stage Other _ Assigned by (Supervisor) Actual Expense,(both columns) = Keys picked up: Amount Charged to Applicant = Staff Member Date Paid , 19 Initials Date Proc'd , 19 Initials Remarks: Fax Notification: Public Works: ` Risk (Ins.) PD Fire Elea Date Date Date Date Date Date Rcvd Apprvl Inst. ' _ Public Works:. Risk (Ins.) PD Fire Elea Date Date Date Date Date Date 12/01/98 Facility Use App.