City of Palmdale

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Application for Permit to Use City Facility

Larry Chimbole Cultural Center Manzanita Ballroom

The ballroom may not be reserved more than 11 months in advance.

* = Required Field

Please use only letters and numbers, commas, periods or apostrophes in the form fields.
Other special characters will not be allowed.

*Person in charge of event:

Organization:

*E-mail Address:

*Confirm E-mail Address:

*Business Phone Number:

*Home Phone Number:

*Address:

*City:

*State:

*Zip:

AREA REQUESTED:

Auditorium		Dance floor		Stage
Kitchen		Dishes		Champagne fountain

*ROOM LAYOUT:

View Room Layout Options

*Date(s) requested:

*Time(s) requested: (Four-hour minimum)

Rehearsal/set-up		From To
Time of event		From To
Clean-up ( 2 hours)		From To ( 2 Hour Minimum )

*Purpose for which facility will be used:

*Expected attendance:

*Please mark YES or NO:

An admission charge/fee will be made.
Yes
No

Will the event be open to the public?
Yes
No

Will alcoholic beverages be served?
Yes
No

Will music (live or DJ) be performed? Yes
No

Will there be a charge for alcohol?
Yes
No

Will food be served?
Yes
No

INSURANCE REQUIRED FOR PERMIT TO USE CITY OF PALMDALE PUBLIC FACILITIES
Before approval of application for permit to use City facilities, it is necessary that a certificate be filed by the person or organization requesting permit, showing liability insurance in force in the name of such person or organization and covering all activities as planned in at least the following limit, and naming the City of Palmdale, the City of Palmdale Redevelopment Agency, and the Palmdale Civic Authority as additional insured. A combined single limit liability insurance certificate in the amount of one million dollars is required for permission to use City of Palmdale facilities.

RELEASE, WAIVER, AND ASSUMPTION OF RISK
I, the undersigned am fully aware and understand there are potential risks involved with the rental of any facility. Specific dangers include, but are not limited to, slip & falls, tripping, equipment failure or accidents, failure of any fixture, structure or structural member, burns, cuts, abrasions, severe injury, death or damage to personal property.

I acknowledge that I am voluntarily renting this facility and participating in the activities conducted therein. I hereby agree to assume all risk of injury, damage to persons and property, and/or death, and to indemnify, defend and hold harmless the City of Palmdale, its officers, agents, volunteers, and employees from any liability for injuries, claim for damage, damage to goods, or death that may arise in connection with the renting or use of this facility. This Release, Waiver, and Assumption of Risk also pertains to any actions of the City of Palmdale, its officers, agents, volunteers and employees (excepting only the sole negligence or willful misconduct of the City) which may have caused or contributed to the injury, damage, or death. This Release, Waiver, and Assumption of Risk shall be binding upon my heirs and dependents as well as myself.

APPLICANT'S STATEMENT
I hereby certify that I have read and will abide by the rules and regulations of the City of Palmdale and the Department of Parks and Recreation as outlined on the reverse and any additional rules that are specific to the facility being used. I understand that fees must be paid at least thirty (30) days in advance of event or permit will be canceled. I further agree to promptly reimburse the City of Palmdale for any clean-up, loss or damage to City property resulting from its use. The City reserves the right to cancel any permit without liability to the Department upon eight (8) days written notice to renter.

*Signature of applicant (must be 21 years of age):

*I have received and read facility rules above: (INITIALS)

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