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REQUEST FOR USE OF <br />CITY OF COLTON <br />PARKS, RECREATION, & FAMILY SERVICES <br />FACILITY USE APPLICATION AND AGREEMENT <br />(909)370-6153 <br />?rN:- K <br />DEPT. USE ONLY <br />Received. <br />Initials <br />Date / Time <br />Processed <br />Date /Initial <br />(DATES) zs&4Er '�-5 C) I Calendar <br />Date / Initial <br />FACILITIES AND EQUIPMENT REQUESTED <br />❑ Main Room ❑ Tablas # <br />❑ Dance Room0 Chairs # <br />c2Activity Room Cl Pool <br />❑ Matin Room NOTE; PLEASE SUBMrr DIAGRAM <br />8 OF SET-UP REQUESTED AT <br />❑ Kitelien 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: To: <br />Program Time: From: )1!nd_ To: (22"_ <br />Clean Up Time: From: To: <br />Purpose of Activity <br />Expected Attendance: Adults 5 U. <br />Youths 3u <br /># of Colton Residents <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 />Application For Facility Use Is: <br />RemingParkr. 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 />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 Will prowee Ins.Broc. <br />Name of Organization A. <br />sTc. rl <br />Name (Diease flint) 4x� C�) V -A -06'r... <br />Signature <br />Contacterson @ly Event <br />Title <br />Address 7 195 <br />City, Zip Code . ] , J7, <br />Phone (daytime) _ 3 tic }� —?DO3 <br />Phone (evening) Ltl # $SZE- in 2i 3 J <br />Data ofapplication—V—� _1�, O) , 20 _ <br />Date Proc'd , 20 _ Initials <br />Fax Notification: ' Public Works: Risk (Ins:) PD Fire Elec. <br />Dote <br />Data . - Date Date Date Date <br />Rovd Apprvl Inst. Public Works: Risk (Ins.) PD Fire Eleo... <br />Dote Date Date Date Date - Date <br />ME <br />