HomeMy WebLinkAboutSouthold Union Free School DistrictKen Reeves ~ 970 Peconic Lane
Recreation Supervisor ~ P.O. Box 267
Town of Southoid Peconic, NY 11958
Ken. Reeves @ town.southold.ny.us 631.765.5182
TOWN OF SOUTHOLD
RECREATION DEPARTMENT
Application for Use of Southold Parks Facilities
Please print legibly
Applications due at least two (2) months before event
Today's Date: July 15, 201 1
RequestingOrgallizaton: Southold Union Free School Distrs~t
Appl~ant'sName: Joseph Bra 5 co
Address: p.o. ~ow 47~, ,q~lll'hc~l~ ~V 11Q71
Home Pllol~e:516- 822- 2666 BIl$iness: 765-5400 Cell: 631- 235-6S )0
Ext. 344
E-MailAddress: jhra~@~n,~thn] ~,,f~ ~Om
Fa~tyDesired: Tennis courts at T~.~k~r zn~ Ca~hr~n P~r~
Day(s) and Date(s) of Use: please see attached
also, practice time Monday -- Friday when courts are
not being used by residents of Southold Town
Requested Time for Field/Park/Court Use:
From: 3:15 PM To: 6~30 PM
Requested time for lights to be on (if applicable):
From: To:
NOTE: lights must be turned offby 10:00 p.m.
Reason for Use (please be specif~ and give details - attach additional sheets if
necessary):
Limited court space at Southold High School
Is admission being charged? Yes No × × × ×
If yes, how much is being charged?.
Please provide a detailed explanation of how the proceeds are to be used:
Applicant's Signature: ~~~, ~
HOLD HARMLESS AGREEMENT
The applieantlgroUl~Or~l-~fion agrees ~ indemnify and hold harmle~ the Town of
Southold, its officials, employees, and/or agents from ail claims, lawsuits, hospital and/or
doctor bills, actions, proceedings, and liabilities for the loss or d~mage to property, or any
injury, the death of a person, including any expenses incurred by the Town of Southold
defei~lin~ any claim~, law~lits, or action that may arise as a result of the conduct, actions,
including the negligence of the applicant/group/organization to the fullest extent permitted
by applicable law.
I have read the attached "SOUTHOLD TOWN FACILITY RULES AND
REGULATIONS" and agree to abide by them.
Name of Organization: ,~l~l-hr~lr] rlnlr~n g'roo ~r~hr~nl District
PLEASE PRINT
~/Da/~ ~'~f// Joseph Braico
te/' ///~ease Pri~Iz~pal/~Author~zed Repr~,=~entative)
FOR OFFICE USE ONLY
Facility Is: Request Is:
A oved
Not available { } Denied { }
~]No
Supervisor
CERTIFICATE OF LIABILITY INSURANCE 07n.~ll
SouthoM UFSD
PO Box 470
Southold, NY 11971
THIS CERTIFICATE IS ISSIJED AS A MATTER OF INFORMATION ONLY
A
~ occua [-- c~^t~s
~PSOUO~I
ECLSOU001
0W01F2011
07/01/2012 PI~SOHAL & ADV II,~URY $ 1,0~0,00O
07/01;2012
CyENERAL ^O(}RE~ATE $ UNLIMITED
PRODUCTS - OOM P,;OP AG(} $ 1,000,0~0
$
S
OCCDRRI~CI~ $
CERTIfflCATE HOLDER
Suffolk County: Towu of Southold / Recreation Department
970 Peconic Lane
P.O. Box 267
Peconic, NY 11958
CANCELLATION