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<br />.lIa <br />[In of [~~~n~[~n <br /> <br />Exhibit C <br /> <br />125 E. Melody Lane <br />Casselberry, FL 32707 <br />(407) 262-7720 <br />Fax (407) 262-7771 <br />After hours dispatch: <br />(407) 262-7606 <br /> <br />Facility and Park Use Application <br /> <br />~~-~---..;~ <br /> <br />1. I, <br /> <br />PARKS 8< RECREATION <br /> <br />, representing <br /> <br />Name of Individual Organization <br />hereby request permission to use the following fadlity/park pavilion (ENTER NAME): <br /> <br />Specific areas or rooms requested: D Pavilion D Entire Facility D Main Room D Ballroom D Meeting Room <br /> <br />2. Date(s)of Use: <br /> <br />Date <br /> <br />Day!s) of Week <br /> <br />Time of Use: From: <br /> <br />AM/PM To: <br /> <br />AM/PM - INCLUDE SET-UP & CLEAN-UP TIME <br /> <br />3. The purpose of this use will be: <br />4. Antidpated maximum attendance: Total Adults Youth <br />5. Is the use of alcohol requested? D Yes D No Sa. Is event open to the public? DYes D No <br />6. Equipment requested (buildings only): # of chairs # of banquet tables <br />7. Will there be decorations? DYes D No If yes, explain: <br /> <br />Will other paid services be used (i.e. moonwalk, commercial caterer, DJ, Band, etc.)? DYes D No <br />Name: Phone: <br /> <br />. Is expressly understood and agreed that the applicant assumes all risks for loss, damage, liability, injury, cost or expense that may arise during or be caused <br />I any way by such use or occupancy of the facfUties of the City of Casselberry and/or Parks and Recreation Department. The applicant further agrees that in <br />,nslderatlon of beIng permitted to use the facilities/parks, he will save and hold harmless the said City of Casselberry, Its officers, agents, employees and <br />volunteers from any loss, claims, and liability damages, and/or injuries to persons and property that In any way may be caused by applicant's use or <br />occupancy. <br /> <br />I, the undersigned, hereby certify to abide by the regulations governing the said fadllty and agree to abide by all City of Casselberry ordinances and leisure <br />facfUty rules and/or polldes, and be representative of the user organization. Further, I agree to be personally responsible for any damage/loss sustained by <br />the grounds, building, furniture or equipment or unusual clean up occurring through the occupancy of said facilities. <br /> <br />Date Completed: <br />Print Name: <br />Signature: <br />Address: <br />City, State, Zip: <br />Phone: <br /> <br />HAVE YOUR COpy OF APPLICATION IN <br /> POSSESSION DURING USE <br />Please type or print clearly with a ballpoint pen. <br />Complete application must be submitted with full <br />payment. <br /> <br />DL#: <br /> <br />- Parks and Recreation Staff Only - <br /> <br />Rental Amount: <br /> <br />Receipt Number: <br /> <br />o Cash 0 Check # <br /> <br />Date: <br /> <br />Deposit Amount: Date: <br />Receipt Number: <br />o Cash 0 Check # 0 Money Order # <br />Key Issued: 0 Yes 0 No <br />Deposit/Key Retumed (Dates): / <br /> <br />o Money Order # <br /> <br />'-30-05 <br /> <br />*7% State Sales Tax is Included in Category I, III, & IV Rental Fees <br />