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DEPT. USE N�y <br />CITY OF COLTON Received. <br />NEIGHBORHOOD SERVICE DIVISION I 't' 1 r <br />Date /Time <br />FACILITY USE APPLICATION AND AGREEMENT <br />(909)370-6153 Processed <br />REQUEST FOR USE OF+ Date /Initial <br />(DATES) kk Calendar <br />Date / Initial <br />FACILITIES AND EQUIPMENT REQUESTED <br />❑ Main Room ❑ Tables # <br />❑ Dance Room ❑ Chairs # <br />❑ Activity Room ❑ Pool <br />❑ 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 />ftd� Fleming Park (Must be approved by Council) <br />tem Stage •-G1f_(Avie—A <br />TIME OF USE <br />(include set-up / clean -uptime) <br />FROM H ' O u p h( -1 <br />TO LA-> <br />Purpose of Activity <br />Expected Attendance: Adults <br />Youths <br /># of Colton Residents `t <br />Is Activity Open to the Public: Yes 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 />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 <br />Ins. <br />Initials - H. H. A..ill process C. <br />Name of Organization UJ <br />Name (please print) '_Vn '� CyJ4eJe , lJC ' (,;A-Z_�p <br />Signature � a u--1, <br />Contact Person @ Event <br />Title <br />Address NQ <br />City, Zip Code C <br />Phone (daytime) <br />Phone (evening) <br />Date of application <br />FOR DEPARTMENT USE ONLY <br />Application For Facility LJse Is: <br />Fleming Park: Council Approved Denied <br />Facility Approved Denied <br />By <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 />Charges <br />tsaunelo <br />Pool <br />Facility <br />Kitchen <br />Cost of Staff <br />Gym <br />Cost of Lights <br />Insurance <br />ria aual L' SJJCRJe kDOrn columns) = <br />Amount Charged to Applicant = <br />Date Paid , 19 Initials <br />Date Proc'd , 19 Initials <br />Y <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 />12/01/98 <br />Facility Use App. <br />� I <br />