Application for Use of Equipment - Canoe/Kayak Boats
Republic Parks & Recreation, 711 E. Miller Road, Republic, MO 65738
P: 417-732-3500 / Fax: 417-732-3590 / Web: http://republicmo.com
Date of Pick-Up:
Date of Drop-Off:
Driver’s License #:
Request Use of the Following:
Item Quantity Fees Amenities (Qty)
1-3 Days Add’l Day(s)
⃝ Canoe ______ $25.00 $10.00 x ____ days Life Jacket(s): ____
⃝ Kayak ______ $30.00 $10.00 x ____ days Dry Bag(s): ____
⃝ Tandem Kayak ______ $35.00 $10.00 x ____ days Paddle(s): ____
Total Amount of Rental Fee: $
Contact Name: _
Telephone: _
Email: _
Address: _
City, State, Zip: ___________________________
It is the policy of the City of Republic to allow the use of
public facilities by members of the community, non-profit
organizations, outside organizations (including for profit
organizations) and school based organizations upon proper
application and approval. In order to maintain appropriate
use of public equipment, before use may be authorized, the
policy located in the yellow-shaded box of this document
must be read and agreed to by the responsible applicant(s).
A fee for facility use will be charged to all non-school and
non-governmental groups to defray the costs of cleaning,
maintenance, utilities, supplies, etc.
By signing below, I acknowledge that I am at least 18 years of age or older and that I have
read the policy located in the yellow-shaded box and assume responsibility and liability for
any bodily injury or property damage caused to myself or any third parties and do herby
agree to hold harmless and indemnify the leaser in the event that any claim should arise from
the use of the canoe or kayak. I also assume responsibility, whether assumed through
insurance protection or personally, for any claims against the City of Republic or City
personnel for any claims arising out of my/our use of any facility.
Signature: ___________________________________________ Date: _____________
Office Use Only Payment Received By:________ Date:_________
Amount Paid: $ ___________ •Cash: _____ •DC/CC: _____ •Check: _____ (Ck # :_______) Copy of License Received: YES NO
Notes:______________________________________
Canoe/Kayak Reservation Policy
•I agree that I am responsible for loading and unloading my canoe/kayak boats.
•I agree to return the canoe(s) or kayak(s) in the same condition as existed at the time of rental.
•I agree to pay for any damages caused to the canoe(s) or kayak(s) and that I am financially responsible for any lost or
damaged items provided by the leaser.
•I agree that all canoes and/or kayaks must be picked up by 5:00 p.m. on Friday’s. No pick-up’s will be permitted on
Saturday’s or Sunday’s.
•I understand that payment is due at the time of reservation.
I have read and agree to the Canoe/Kayak Reservation Policy. Initials: ____________
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