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CITY OF COLTON <br />HUMAN SERVICES DEPARTMENT <br />APPLICATION AND AGREEMENT FOR FACILITY USE <br />REQUEST FOR USE OF / Facili /Pool/Fiel Park <br />l I 1 (Circle One) <br />ON (DATES) <br />FACILITIES AND EQUIPMENT REQUESTED <br />❑ Multi -Use Room anquet Tables # <br />❑ Activity Room ;4- Chairs #� <br />❑ Community Room �ystem <br />❑ Kitchen ❑ Other <br />❑ Baseball Diamond <br />❑ Pool <br />TIME OF USE <br />FROM <br />TO <br />AM.6 <br />1. Purpose of Activity: <br />2. Expected Attendance: Adults <br />Youths <br />3. Is Activity Open to the Public: <br />Yes ��- No <br />4. Will Admission Be Charged: <br />Yes No l <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 />Approved Denied <br />By <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 REGULATIO S 0? <br />THE BACK <br />OF THIS APPLICATION. 12 <br />Nam ofbrg nization <br />/n _ <br />At <br />Name (please prin <br />Signature <br />Title <br />Address <br />City, Zip Code <br />Phone (dayt74-' <br />) Date /C) <br />FOR DEPARTMENT USE ONLY <br />Approval Is Subject To Conditions Listed On Back <br />Deposit <br />Fee <br />White - Office <br />Yellow - Permittee <br />Pink - Facility <br />Goldenrod - Public Works <br />Remarks <br />Date Paid <br />Date Processed <br />I <br />,19 <br />,19 <br />19 <br />n <br />