City of Merced Parks and Community Services *On Call (209) 564-9103 678 W 18th Street For Rental Problems
Merced, CA 95340
(209) 385-6855
APPLICATION AND AGREEMENT FOR USE OF FACILITIES
Applicant’s Name:
ELISABETE DOBBINS
Address: City: Zip Code:
Name of Organization:
CHANCE DOBBINS SR. CHARITY/CLUB 67
Primary Phone (Area Code): Secondary Phone (Area Code):
Room to be reserved - Please Circle:
Rossotti Ed-Zoo-Cation Rotary Scout Hut
Sam Pipes Conference Room Council Chambers Merced Community Senior Center Nature of Event:
SOCIAL & DANCE
Event Date:
ONE FRIDAY
PER MONTH
Time:
5:00 PM – 11:00 PM
Estimated Attendance
100 - 150
Public Event?
Yes No
Event used to
raise money?
Yes No
Admission
Charged?
Yes No
Equipment Requirements:
Senior Center Use Only
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 Chairs and tables – banquet style
Event time is 6pm – 10 pm. Requesting 6 hours total to include set-up and clean-up.
APPLICANT’S AGREEMENT
I have read this agreement and accept the facility for which this application is made in an “AS IS” condition. In consideration of the minimal fees paid for use of the facility, the applicant is to indemnify, defend and hold harmless the City of Merced, its of ficers, officials, employees, agents, and volunteers (“City and City Personnel”) from all actions, liabilities, claims, damages to persons 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 negligence on the part of City or City Personnel. The use of glitter or confetti is prohibited. Alcohol is not allowed at any of our facilities, except the Senior Center.
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. Refunds may be subject to a 25% assessment fee for administrative costs. Failure to cancel within the specific time frame will result in forfeiture of deposit and all rental fees.
Signed_________________________________________ Date_______________________________________
-OFFICE USE ONLY-
FEES
Contracted Hours 6 @ $75 $ 450
Deposit ($150/event) $ 0 (on file)
Set-up Fee $ 62.50
Cleaning Fee $ 183
Bounce House Fee $ N/A
TOTAL
$ 695.50
Please make check payable to City of Merced.
* Returned checks will result in cancellation of event
and/or additional charges.
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. (Through City’s Insurance Dept.)
Security Contract
Dance Permit
ABC License (if liquor is to be sold)
Added to Computer By: _____________________
CO-SPONSORSHIP RENTAL FEES