City of Palmdale

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Chimbole Cultural Center

Application for Room Rental

This is not a reservation guarantee. Applicants must apply ten (10) days prior to rental date. Reservations are not guaranteed until Renter receives written confirmation in the form of a Rental Contract from the City of Palmdale Department of Recreation and Culture and all conditions and terms of the contract are met. A security deposit does not indicate a reservation guarantee.

* = Required Field

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

*Name of Applicant:

Organization:

*E-mail Address:

*Confirm E-mail Address:

*Business Phone Number:

*Home Phone Number:

*Mailing Address:

*City:

*State:

*Zip:

*Rental Date(s) Requested:

*Expected Attendance:

*Purpose of Rental:

*Rooms Requested:

Primrose Room (south)	Capacity: 40
Sage Conference Room	Capacity: 20
Joshua Room (center)	Capacity: 22-64
Lilac Room (north)	Capacity: 22-52

*Items Requested:

Podium

TV/VCR/DVD

Projection Screen

*ROOM LAYOUT:

View Room Layout Options

*Rental Time(s):

Setup/Load-in Times:		From To
This is applicable if Renter requires time to prepare for the rental.
Event/Meeting Rental Times:		From To
Clean-up Times:		From To
This is applicable if Renter requires time to clean-up the rental.

*Please Mark YES or NO:
Will the event be open to the public?	Yes No
City to determine necessary security requirements
Will amplified sound be used?	Yes No
Are you requesting to serve food?	Yes No
Food is only allowed in the Primrose Room. Alcoholic beverages are not permitted.

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 attached and any additional rules that are specific to the facility. I understand that fees must be paid at least ten (10) days in advance of rental or Rental Contract will be cancelled. I understand that if I cancel this rental I must do so in writing ten (10) days prior to rental date to receive a refund. I understand a signed Rental Contract must be received at least ten (10) days prior to rental date. I further agree to promptly reimburse the City of Palmdale for any clean-up, loss of damage to City property resulting from its use within five (5) days of conclusion of rental date. The City reserves the right to cancel any rental without liability to the Department upon ten (10) days written notice to Renter.

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

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

En Español/Other Languages: