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CITY OF COLTON <br />HUMAN SERVICES DEPARTMENT <br />APPLICATION AND AGREEMENT FOR FACILITY USE <br />REQUEST FOR USE OF Facility/Pod/Fiel Park <br />-- <br />ON (DATES) ,�� n Jan Y [ 01 t q— 4 (Circle One) <br />FACILITIES AND EQUIPMENT REQUESTED <br />El Multi -Use Room (3 Banquet Tables # <br />d Activity Room ❑ Chairs # <br />U Community Room ❑ P.A. System <br />17 Kitchen ❑ Other <br />Baseball Diamond _fib <br />0 Pool <br />2 TIME OF USE <br />FROM 3 100 Aane <br />fi0 00 AMM�J�.�' <br />1. Purpose of Activity: <br />2. Expected Attendance: Adults IGO <br />Youths <br />3. Is Activity Open to the Public.- <br />Yes <br />ublic:Yes No <br />4. Will Admission Be Charged:' / <br />Yes No X <br />5. Will Donations Be Accepted: <br />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 <br />abuse of buildings, grounds or equipment through the use <br />of said premises by our organization. <br />WE AGREE TO ABIDE BY AND ENFORCE THE RULES AND <br />REGULATIONS OF THE CITY OF COLTON AND CERTIFY THAT <br />WE HAVE READ THE RULES AND REGULATIONS ON HEBACK <br />OF THIS APPLICATION. f �1 <br />Name of Organization <br />Name (please print) <br />Title <br />Address <br />CiN, Zip Code <br />N O - Gam, 4 <br />v AJ0L)-s-I ;Y,'-3 � i�► 9.3 <br />FOR DEPARTMENT USE ONLY <br />Application For Facility Use Is: <br />Approved Denied <br />By <br />Approval Is Subject To Conditions Listed On Back <br />Deposit <br />Fee <br />White -Office <br />Yellow - Permittee <br />Fink - Facility <br />Goldenrod - Public Works <br />Remarks <br />Date Paid <br />Date Processed <br />~v -A k <br />NOV <br />ly <br />A. <br />,19 <br />19 <br />6. <br />