City of Merced Parks and Community Services *On Call (209) 564-9103 632 W 18th Street For Rental Problems
Merced, CA 95340
(209) 385-6855 fax (209) 726-5327
APPLICATION AND AGREEMENT FOR USE OF FACILITIES
Applicant’s Name:
Address: City:
Zip Code:
Name of Organization:
Day Phone (Area Code):
Evening Phone (Area Code):
Room to be reserved - Please Circle:
Sam Pipes Conference Room Merced Community Senior Center Nature of Event:
Event Date:
Time:
10 AM TO 3 PM
Estimated Attendance
Adults Minors Total
Public Event?
Yes No
Event used to
raise money?
Yes No
Admission
Charged?
Yes No
Equipment Requirements:
Chairs - Theatre Style
Chairs and Tables – Classroom Style
Chairs and Tables – Banquet Style with Dance Floor
Stage
Kitchen Facilities
Portable Coffee Maker(s)
P.A. System
U.S. Flag
California Flag
Other: Event time is 11 AM to 2 PM. Requested 2 hours for set up on Friday, October 7th. Renter to receive one hour before
(set up) and one hour after (cleanup) event. Total use time, including Friday set up is 7 hours.
ADDITIONAL DATES:_______________________________________________________________________________
APPLICANT’S AGREEMENT
I have read this agreement and accept the facility for which this application is made in an “AS IS” condition. In considerat ion of the minimal fees paid for use of the facility, the applicant is to indemnify, defend and hold harmless the City of Merced, i ts officers, officials, employees, agents, and volunteers (“City and City Personnel”) from all actions, liabilities, claims, damages to pe rsons or property, losses, costs, penalties, obligations, errors, or omissions that may be asserted or claimed by any person, firm, or entity arising out of or in connection with the activities conducted by the applicant, whether or not there is concurrent passive or neglige nce on the part of City or City Personnel.
NOTICE TO APPLICANT:
All rentals must be cancelled no later than 2 weeks before the event date, except the Senior Center, which must be cancelled at least 30 days before the event. A “Refund Appeal” must be filled out when requesting a refund and may be subject to a 25% assessment fee for administrative costs. Failure to do so will result in forfeiture of deposit and all rental fees.
Signed_________________________________________ Date_______________________________________
-OFFICE USE ONLY-
FEES
Contracted Hours $ 7 @ $ 125 = $__875.00___________
Deposit (refundable) $__ 300.00___________
Set-up Fee $__ 100.00__________
Kitchen Fee $__________________
Cleaning Fee
$__ 366.00__________
TOTAL $__1641.00__________
Department Authorized Signature:
________________________________________Date: _______________
Approved Denied
Set up Diagram (at least 2 weeks prior to event if applicable)
Certificate of Insurance in compliance with City of
Merced
Contracted Security/Dance Permit
ABC License (if liquor is to be sold)
Added to Computer By: _____________________
Please make check payable to City of Merced.
Returned checks will result in cancellation of event
and/or additional charges.
STANDARD RENTAL FEES