FACILITY USE APPLICATION & PERMIT FORM
All requests for use of facilities must first be approved by the City at least 48 hours in advance
A COPY OF YOUR CERTIFICATE OF INSURANCE MUST ACCOMPANY THIS APPLICATION
City of El Mirage - Customer Service - 14406 N Alto St., El Mirage, AZ 85335
Date(s)
Requested
One-time use
Date:
Day:
Multiple dates use (List each date):
Time
Requested
Day:
Su
M
Tu W
Th F
Sa
Start time:
a.m.
p.m.
End time:
a.m.
p.m.
Ramada 1 Ramada 2
Ramada 3
Facility Requested
(Location: i.e., Gateway Park)
Ramada 4 Ramada 5 Ramada 6
Area Requested
(ie, Field #1)
Equipment Requested
Scoreboard
Base
Tables
#
Chairs
#
Other:
Set-up Requested
Classroom Theater Hollow Square
U-Shape
Conference
Other:
Special Instructions
Does activity service
El Mirage
Residents
Yes
# of Residents
Served:
Participant
Discount to
Fee: $
Residents
Request for Waiver of
Fees (Attach)
Any governmental or non-profit agency may request a waiver of fees for facility use. If requesting a waiver of fees, please include a
narrative explaining why the City of El Mirage should grant your request and how both the City and its residents will directly benefit from
the planned event. Upon review by the City Manager, a city representative will contact the applicant regarding the approval or denial.
Name of Organization
Designation
Non-profit
Profit
Commercial Government
Nature of Activity
Applicant Responsible
(Please Print)
Telephone
Work
Cell
Home
Mailing Address
City
Zip
Thank you for choosing the City of El Mirage for your rental needs. Your patronage is valued and your rental is important. Should you have any comments, questions or
concerns please phone (623) 935-6405, Monday through Thursday, between 6:00am and 3:00pm. In the event that you incur a problem after 3pm on weekends and
holidays, please phone (623) 933-1341 and the Police Dispatcher will contact the appropriate personnel to assist you.
Indemnification: The applicant and organization identified above hereby
agree to indemnify, defend and hold harmless the City of El Mirage, and its employees, officers,
elected officials, agents and anyone acting on or for its behalf (hereinafter collectively "City”) from any and all liability, loss, claims, demands, litigation, causes of action,
court costs, attorneys’ fees and other expenses arising from or related to any loss, damage or injury (including death) to person or property in any way resulting from,
arising out of or alleged to result from or arise out of the use of the City of El Mirage facility(ies) by me, the above identified organization or any persons invited o
r
permitted by me or the organization to use the facility(ies), whether or not such loss, damage or injury is attribut
able, or alleged to be attributable, to the negligence of
others, including the City.
Assumption of Risk and Release: I and the organization know the risks and dangers, from both known risks and unanticipated risky, of usi
ng t
he facility(ies) described
above in the manner specified, and do so voluntarily and in reliance upon our own judgment and ability, not upon the property, equipment, facilities and existing conditions
furnished by others, including the City. As consideration for being permit
ted to use the facility, I and organization, on behalf of ourselves and those whom we invite or
permit to use the facility(ies), assume all risk of liability, and
agree to release and waive the City of El Mirage of liability, for any loss, damage or injury (including
death) to person or property from any cause whatsoever, whether or not attributable to the negligence of others including the City of El Mirage, arising out of the use
of the facility in the manner set forth above and during the dates and times specified. This Assumption of Risk and Release shall also apply to any minor under 18 years
of age whom we may bring or allow participating in any event or activity in, on or at the facility.
Revised 10/16/2019
Signature of Applicant
Date
No
click to sign
signature
click to edit
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