HomeMy WebLinkAboutGardiners Bay Estates Homeowners Assoc. Oysteq2onds Unio~ Free School DJstt]ct
23405 Main Road Telephone (631) 323-2410
Orient, NY 11957
Joan C. Frisicano
Superintendent of Schools
Fax . (631) 323-3713
Website xvww.oysterponds.org
Frangoise Wittenburg
Principal
APPLICATION FOR USE OF SCHOOL DISTRICT FACILITIES
Today's Date: ,...Jt)/9~' [~, 7_,0[7_. Date (s) Requested: AOC_.~ ,4, 7~5~t2-
Facility Requested: tT~,tP,~. O/~ Jk[.. ~:'~). ~./v~t(g::l,q Room: '---"
INFORMATION ABOUT GROUP
Name of Organization or Individual:
Time: ~ ~P~ to ~ eH . Supervisor incharge:
Mailing Address: ~ ~.t~), ~K, ~5'~:pr
Telephone: (Day) iL 7/T- f_.) ~zS-' (Night)_
INFORMATION ABOUT INTENDED USE OF SCHOOL DISTRICT FACILITY
PurposeofUse: 7~,t5) .~1-.~ ~'{~-Z:7/'f) ~,Z~(7~. ffT~FY/,~'&'-"~,{~
Total Participants Expected: 7,~--
· equipment required7 Yes
If needed, state what type and for what purpose:
Residents (Number): /ff
Is an admission fee charged? Yes
tg-sor-what-w~ proceeds be used for?
If refreshments are served, give details:
Adults:
No
Non-Residents (Number):
AGREEMENT
The undersigned is over 21 years of age and has read this form and attached regulations and agrees to comply with them.
He/she agrees to be responsible to the District for the use and care of the facility. He/she, on behalf of
~t~HO~ff' does hereby covenant and agree to defend, indemnify and hold harmless
the District from and against any and all liability, loss, damages, claims, or actions (including costs and attorneys fees) for
bodily injury and/or property damage, to the extent permissible, by law, arising out of or in connection with the actual or
proposed use of District's property, facilities anO/o~servi,ce~_by~gani, z.ation./_
Signature of Organization's Representative: (~ ~ ~//2
~,
Address: :~b/ O/-~ ~'//x/~'- /-V0. fi~/OA~7~t~]"fi~//~/~ Telephone Number:
Agnature o f Superintendent ~ fL~ Date:
READ ATTACJ~D REQUIREMENTS AND RETURN APPLICATION TO:
OYSTER.PONDS UFSD 23405 MAIN RD ORIENT NY 11957, ATTENTION: MRS. JOAN FRISICANO
12/11/2009 RVSD 1/30/2012
KEN REEVES
RECREATION SUPERVISOR
TOWN OF SOUTHOLD
970 Peconic Lane
P.O. Box 267
Peconic. NY 11958
631.765.51~2
Ken.Reev~to~.sou~old.ny.us
TOWN OF SOUTHOLD
RECREATION DEPARTMENT
APPLICATION FOR USE OF SOUTHOLD PARKS FACIILITIES
PLEASE PRINT LEGIBLY
t
REQUESTED TIME FOR FIELD,ARK]COURT USE:
REQUESTED TIME FOR LIGHTS TO BE ON (IF APPLICABLE):
FROM: TO:
NOTE: LIGHTS MUST BE TURNED OFF BY 10:00 P,M.
REASON FOR USE(PLEASE BE SPECIFIC AND GIVE DETAILS):
IS ADMISSION BEING CHARGED. YES NO t~
IF YES. HOW MUCH IS BEING CHARGED? ~
PLEASE PROVIDE A DETAILED EXPLANATION OF HOW THE PROCEEDS ARE
TO BE USED:
' I, II '.'..---," - ;t/ ...- 0
APPLICANTS SIGNATURE. ~(~l~r.~
HOLD HARMLESS AGREEMENT
The applicant/group/organization agrees to indemnify and bold harmless the Town of
Southold, its officials, employees, and/or agents from all claims, lawsnlts, hospitol and/or
doetor bills, actions, proceedings, and liabilitie~ for the io~s or damage to property, or ~.
injury, the death of a person, including any expenses Incurred by the Town of
Southold~
defending any claims, hwsnits, or action that may arise as a result of the conduct, a~ons,
Including the negligence of the applicant/group/o~anization to the fullest ex~ent permitted
by applicable law.
I have read the attached "SOUTHOLD TOWN FACILITY RULE~ AND
REGULATIONS" and agree to abide by them.
PLF_~,SE PRINT
/ DATE PLEASE PRINT (PRInCIPAL/AUTHORIZED REPRESENTATIVe) ~
FOR OFFICE USE ONLY
FACILITY IS: REQUEST IS:
AVAELABLE { ~ h ' ' APPROVED
NOT AVAILABLE { } DENIED { }
CERT~A~_~INSURANCE REQ~D?
Rect~eation Department
~S ~ NO
Town of Southold Police Department
Special Event Cost Analysis
Event: Community Yard Sale
Location: Old Schoolhouse Part(, RL 25, East
Patrol Ailo~ for Eve~tt
~Reg. Hours OT Hrs Hrly Wa~le . Total Comments
~egHours !OT.H_rs _tHl!YWage .... ?_o~_1
K.~ Uldl
~ Houm lOT Hrs Hrly We,e Total i - __Comments
TC Officer 8~ $15.83 $126.64 ~ .......
TC Officer
TC Officer ~
TC Officer i
?ot~lB~rtm~nt¢o~t~orfi¥~nt--- '" $- ...............
Prepared by Capt. M. Flatley 4/11/2011~/~
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