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SPECIAL EVENT PERMIT APPLICATION

Polk County Conservation

12130 NW 128

Street

Granger, IA 50109

515.323.5300 Phone

515.323.5354 Fax

In order to determine if your event will require a Special Event Permit from the Polk County Conservation Board,

you must begin the application process at least a minimum of 45 days prior to the requested date of the event.

Advertising your event prior to receiving a signed Special Event Permit is not allowed. This application must

be completed in its entirety before a permit will be issued.

1. EVENT INFORMATION:

NAME OF EVENT (Example: Smith/Doe Wedding, ABC Company Annual Picnic, etc.)

DATE OF EVENT: LOCATION:

(Example: Jester Park, Shelter #1)

STARTING TIME: ENDING TIME:

TYPE OF EVENT:

A) Ceremony _______ E) Golf Outing _________

B) Company Activity _______ F) Fund Raiser _________

C) Bike Event _______ G) Cultural Event _________

D) Race Event _______ H) Other ___________________

(Please List)

DESCRIBE ACTIVITIES AT THE EVENT:

2. CONTACT INFORMATION:

PERSON RESPONSIBLE FOR APPLICATION:

ADDRESS:

CITY: STATE: ZIP:

CONTACT TELEPHONE NUMBER: DAY EVENING

FAX: EMAIL:

ALTERNATE CONTACT PERSON:

ALTERNATE CONTACT NUMBERS: DAY EVENING

For specific park information regarding

your event, contact:

Jester Park – 515.249.3229

Thomas Mitchell Park – 515.249.1753

Easter Lake Park – 515.249.1543

Yellow Banks Park – 515.250.1031

Chichaqua Bottoms Greenbelt – 515.249.2515

Ft. Des Moines Park – 515.249.1543

3. EVENT DETAILS:

A. PARTICIPANTS:

 Number of People

 Number of Vehicles

 Invited Guests Only: Yes No

 Open to General Public: Yes No

 Organization/Club Members Only: Yes No

 Registered Participants Only: Yes No

B. VENDOR PARTICIPANTS (Appropriate vendor permits are required and must be posted at each vendor

site on the day of the event):

 Number of Vendors

 List of Vendors:

C. SPECIAL CIRCUMSTANCES (Describe if any of the items listed below will be brought in by the user for

the event. All items brought in must be removed immediately following the event otherwise

maintenance staff fees may be assessed. Insurance coverage may be required for some activities listed

below):

 Tents: Yes No Qty._________

o If yes, describe tent, size, number and location

 Inflatable Bounce Houses/Toys/Slides: Yes No

o If yes, describe type, number and location

 Amplified Music: Yes No

o If yes, describe use of

 Banners*: Yes No

o If yes, describe use of

* Banners may be placed along roadways to guide people to your event, but in no way may be affixed to

trees or park signs. Signs are to be removed immediately following event. Failure to do so will result in

maintenance fees and/or fines according to littering ordinances.

 Signs*: Yes No

o If yes, describe use of

* Small directional signs may be placed along roadways to guide people to your event, but in no way may

be affixed to trees or park signs. Signs are to be removed immediately following event. Failure to do so will

result in maintenance fees and/or fines according to littering ordinances.

 Trash Containers: Yes No

o Date Brought In: Date Removed:

 Portable Toilets: Yes No Qty.____________

o Date Brought In: Date Removed: _______________

 Alcoholic Beverages to be Served? Yes _______ No _______ Qty. ________

(Intoxicating liquors are not allowed; beer and wine only. Sec. 27 – Polk County Conservation Rules and

Regulations)

D. INSURANCE - Polk County Conservation’s liability insurance excludes the use of aircraft on park property

including hot-air ballons, planes, helicopters, ultra-lights and parachutes. Applicants of special events may be

required to furnish a Certificate of Insurance on a fully paid comprehensive public liability and property damage

insurance policy from a licensed broker, protecting Polk County, the Polk County Conservation Board, its officers,

elected officials, and employees, agents and assigns from any and all claims which may result from or in connection

to the special event. Polk County and the Polk County Conservation Board must be named as “Additional Insureds”

on the certificate. Applicants must, if required by the Polk County Conservation Board, produce a copy of the policy

with all endorsements. Polk County Conservation must receive the certificate at least ten (10) days prior to the

special event. Limits and type of insurance coverage may change because of the different activities of each special

event. The Polk County Risk Manager will determine all specific limits and types of insurance appropriate for the

special event. Proof of insurance (if applicable) must be received by Polk County Conservation before a Special

Event Permit will be issued.

E. SPECIAL PROVISIONS (Need for items provided by Polk County Conservation staff):

 Extra Picnic Tables ($20 for each additional added to area): Yes No

o Number of extra tables requested:

 Ranger/Security Staff: Security may be assigned/required by the Parks Superintendent upon review of

this application and will be billed at a rate of $75/hour per staff person.

 Maintenance Staff ($75/hour per staff person): Yes No

 Other (Describe):

*Events serving alcohol shall require one Law Enforcement Officer to be on-site during said event.

F. TRAFFIC & EMERGENCY SAFETY

 Access to Event – Do you anticipate that your event will interfere with non-participating vehicle traffic,

crowd and/or traffic control? Yes ____________ No ___________ unsure ________

 Emergency Preparedness --Do you anticipate the need for first aid booths, fire/rescue units present

during your event? Yes ____________ No ___________ unsure ________

G. FEES/CHARGES/DEPOSITS – All fees, charges and deposits must be paid before a Special Event Permit will

be issued.

 Rental Charges – Associated rental facility fees and damage deposits shall apply should a facility within

the PCC jurisdiction be used in conjunction with the event.

 Administration Fee – A $50.00 administration fee will be charged to process the Special Event Application

and must be received by PCC before permit will be issued.

 Damage Deposit – A damage deposit (amount determined by PCC staff) may be required. Following the

event, PCC staff will inspect the area and if the area is not left in the condition prior to the event, the damage

deposit will be forfeited. If the dollar amount for any repair/clean-up exceeds the deposit, additional fees at

$75/hr/maintenance person will apply. The party shall be billed for the balance and shall be paid in full no

more than 30 days from the billing date.

PCC looks forward in assisting you in determining these concerns as well as any other concerns or issues you may

have in this application process.

I have completed the Special Event Application, enclosed appropriate fees and understand the conditions under

which it is issued and agree to comply with these conditions for this event.

Signature: Date:

Print Name:

The Privacy Act of 1974 requires that each individual asked or required to furnish personal information be advised

of the following:

Authority: 5 P.L. 93-579

Purpose: To provide a contact in connection with permit activities.

Routine Uses: Permit is issued under the direction of the Polk County Conservation Board. The names and

addresses of those who obtain the permit are not reported, but are kept on file at the Conservation Board office to

provide a point of contact in case of emergency. This information is not maintained alphabetically or by other

personal identifier. Disclosure of information is voluntary. Failure to provide the requested information will preclude

issuance of permit. Failure to meet the terms of this Special Event Application may prompt additional fees to be

charged at a rate to be determined by the Polk County Conservation Board.

Approved by Park Ranger: Date:

Approved by PCCB Parks Superintendent: Date:

OFFICE USE ONLY:

(PCC Staff: Please complete this section in case this sheet gets separated from original application).

Date of Event: __________________________ Location: ________________________________

Name of Event: ___________________________________________________________________

Contact: _________________________________________________________________________

Address: _________________________________________________________________________

Street City State Zip Code

Verification of Fees: Description Cost per Item Qty. Total

Park Use Fee $250.00 (if public use is restricted) Or

$10.00 per hour

Ranger/Security Staff $75.00/Hr.

Picnic Tables $20.00 Ea.

Maintenance Staff $75.00/Hr./Person

Vendor Fees: $25.00/ea.

Administration Fee: $50.00

Other Fees:

Damage Deposit

Recommended: Amount $

(Continued on next page.)

Special Considerations and Conditions:

__________________________________________________________________________________

Initials: ________

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