Town of Gardnerville

ParkUse/StreetClosure/SpecialEventApplicationReservationForm/Releaseof Liability/IndemnificationAgreement

DateofApplication(must besubmitted 10 businessdayspriorto event):

Organization:Corporation: Yes ___ No

(Ifa corporation, acopy of theArticlesofIncorporationmustbeattached)

ContactPerson:email: ______Home/CellPhone:______

BusinessPhone:Fax:

MailingAddress:(Ifcorporation,attachhome or businessphoneand addressesofpresident,vice-presidentand secretary)

Requesting: MitchPark Isrequestforexclusiveuseof park: Yes___ No

IfMitch Park butnotexclusive use, describewhichareaof parkis beingrequested:

Requesting:Street Closure

Street(s) proposingto beclosed:

Nameand description ofevent, concessions,fund-raiser,etc.:

Eventdates:

Event hours(includingsetupteardown):

This event is: _____For ProfitClosed to the public_____ Open to the Public ______

_____Non Profit

(Non-profitorganizationsmustsubmitIRS 501cletter withapplication)

Ifnon-profitevent,describe who benefitsfromproceeds ofevent:

(DouglasCountyOutdoorFestivalPermitisrequiredifmorethan 500attendeesexpectedon any day ofevent)

EventInsuranceCarrier:Phone:______

Numberof patrons,customers,spectators, participants,etc. expected toattend oneach dayof the event ______

CertificateofInsurance mustbeattached tothisapplicationandmustnametheGardnerville Ranchos GID asadditionalinsured,anddate and location ofthe event -see SpecialEventPolicyforpolicylimit

Isafeechargedtoattendtheevent: Yes ___ No_ Is food beingserved:Yes___ No_ Willalcoholbe soldorserved: Yes___ No_ Willthere bebandor amplifiedmusic: Yes ___ No_

Ifyes,HealthPermit#Liquorlicenses/permitsmay be required

Willyouhavetents,canopies,bouncehouses,dancefloors,etc.? Yes

No

Ifyes,specifyquantity,dimensions,etc:

(Stakesare notpermittedfor usein securingtents,etc.; bouncehouses, dancefloorsortentslargerthan 20’x20’

may be subjectto additionalsecuritydepositsand/orinsurancecoverage)

Clean-up/Sanitation/Garbage Plan:

(Groupsof50 or morearerequiredto pay a minimum ofone $25dumpsterservicefee;parkrestrooms

accommodatea maximumof100people,oneport-a-potty isrequiredforevery100peopleover100)

WaterandSanitationPlaniffoodsold orconsumed during event:

(Gardnerville Ranchos GID watercouplerisavailableifyou usehosesforwater)

OtherGardnerville Ranchos GIDservices,ifrequired:

(Electricaloutlets,pavilionlighting,etc.)

EventParkingArea:(Eventcannotblockdrivewaysofprivateresidencesaroundpark. Pleasenotethatdirt loteastofMitch Park isprivatepropertyand may notbeusedforparkingunless aletterofowner’spermissionis submitted)

Fire/EmergencyMedicalServicesPlan:

(SubmitEastForkFireProtectionDistrict authorization and approval)

SecurityPlanifovernightuse ofGardnerville Ranchos GIDfacilitiesplanned:

(SubmitDouglasCountySheriff’sOfficeauthorizationand approval)

EventLayout: All applicantsMUSTprovidea drawing(s)clearlyshowingeventarea(s),streetsrequestedforclosure,boothspaces,etc.Ifrequestinguseof Mitch Park,a Gardnerville Ranchos GIDfurnishedtemplatewillbe providedindicatingutilitylinesandothereventconstraints.

Acopy oftheapprovedformMUSTbe attheevent

WAIVER OF LIABILITY

The UNDERSIGNED, forhimself/herselfand on behalfoftheabovenamedApplicantOrganizationorBusiness,does herebyagreeto protect,indemnify,saveand keepharmless,the Gardnerville Ranchos GID,itselectedandappointedofficials,employeesandvolunteers andothersworkingonbehalfoftheGardnerville Ranchos GID, andDouglasCounty,Nevada,from any andallclaims,demands,suits orloss,includingallcostsconnectedtherewith,includingbutnotlimitedtoreasonableattorney’sfees,administrativecosts,and courtcostsand forany damageswhich maybeasserted,claimedor recoveredagainstorfromtheGardnerville Ranchos GID,itselected

and appointedofficials,employees,volunteersor othersworking onbehalfoftheGardnerville Ranchos GID, byreasonofpersonalinjury,including butnotlimited tobodilyinjuryordeath,and/orpropertydamage,includinglossofuse thereof,whichariseoutoforisin any wayconnected or associatedwiththisReservationForm and Release ofLiabilityandIndemnificationAgreement.

I do herebycertifythat,in representationofthe above-namedApplicantOrganization orBusiness, Ihave receiveda copyoftheGardnerville Ranchos GIDParkUse and ReservationPolicyandtheGardnerville Ranchos GID StreetClosure/SpecialEventsPolicy,thatI havereadthosepolicies, andthattheabove-namedApplicant Organization orBusinesswillobserve allrulesandregulationscontainedtherein,includinganyconditions of approval oftheGardnerville Ranchos GID Board, andany otherconditionsand/orrequirementsthatmaybe setforthbyDouglasCounty,Nevada.

AuthorizedRepresentative(s) ofApplicant:

Signature PrintedName Date

(Ifapplicantis acorporation,must includesignatureofpresident,vice-president,and secretary ofcorporation)

(Gardnerville Ranchos GIDUseOnly)

Mitch Park:

Usage$25/hr($300/daymax)Paid$Date: ParkDeposit$300Paid$Date: Dumpster$25/each Paid$ Date:

AdditionalFees/Description $DepositRefunded Paid$ Date: FacilityReviewed:

StreetClosure:

ApplicationFee$100Paid$Date:

Scheduledfor GRGIDBoardAgenda:Approved: