*AREA REQUESTED:
*ROOM LAYOUT:
*Date(s) requested:
*Time(s) requested: (Two-hour minimum)
From To
*Purpose for which facility will be used:
*Expected attendance:
*Please mark YES or NO:
Will the event be open to the public?
Yes
No
Will admission be charged?
Yes
No
Will live music be performed?
Yes
No
Alcoholic Beveragest Not Permitted.
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)
|
BUSINESS
HOME
CONTACT CITY STAFF