Application for Use of Public Facilities Room Rentals
Republic Parks & Recreation, 711 E. Miller Road, Republic, MO 65738
P: 417-732-3500 / Fax: 417-732-3590 / Web: http://republicmo.com
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Date of Application:
Name of Ind./Org.:
Date(s) of Rental:
Times of Rental:
Purpose of Rental:
Request Use of the Following Facility:
Facility Area Non-Profit Fees (Per Hour) For Profit Fees (Per Hour)
1-4 Hours 5+ Hours League 1-4 Hours 5+ Hours
Republic Community Center ⃝ Community Room A $30.00 $22.50 N/A $40.00 $30.00
⃝ Community Room B $40.00 $30.00 N/A $55.00 $42.00
⃝ Community Rooms A & B $60.00 $45.00 N/A $80.00 $60.00
⃝ Republic Activities Building ⃝ Community Room C $20.00 $15.00 N/A $30.00 $22.50
⃝ Republic Senior Friendship Center ⃝ Banquet Room $20.00* $10.00* N/A $20.00* $10.00*
*The Senior Center’s minimal rental period is four (4) hours at the full rate. Each additional hour will be charged at the 5+ hours rate.
Total Amount of Rental Fee: $
Contact Name: _
Telephone: _
Email: _
Address: _
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 facilities, before use may be authorized, the
policy located on the back side 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 on the back side of this document and assume responsibility and
liability for any damage or loss to the facility or its contents during the use of the facility by
the above-named individual/organization. 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 # :_______) Set-Up Form Received: YES NO
Notes:______________________________________
Room Reservation Policy
•All Room Reservations must be paid for in full at the time of reservation.
Payments can be made over the phone with a credit card after this Room Reservation Form is received.
I have read and agree to the Room Reservation Policy. Initials: ____________
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Application for Use of Public Facilities Room Rentals
Republic Parks & Recreation, 711 E. Miller Road, Republic, MO 65738
P: 417-732-3500 / Fax: 417-732-3590 / Web: http://republicmo.com
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Policy Community Use of Public Facilities
The City of Republic recognizes that use of public facilities by individuals or organizations can benefit the citizens of the Republic community. The City of Republic may
authorize use of public facilities as defined below.
1. Definitions
A. Non-Profit Organizations shall include civic, religious, government, or community organizations that either qualify as 501-C-3 non-profit, as defined by the Internal Revenue Service,
or do not operate for commercial/private gain.
B. Outside Organizations those organizations (including for profit organizations) whose presence benefits the City of Republic or the Republic community.
C. School Based Organizations those volunteer organizations generated by the existence of the school, including booster clubs, direct support organizations, parent-teacher
organizations or associations, etc.
2. Fee Structure
All individuals/organizations using public facilities shall agree to pay the City of Republic the rental fees as set out on the structure sheet on the front side of this document.
Returned/Insufficient Fund Checks will be charged a $20.00 fee and must be settled at Republic City Hall.
3. Regulations
The possession or consumption of alcohol is prohibited at the Republic Community Center, Republic Activities Building, or the Republic Senior Friendship Center.
No smoking is allowed at the Republic Community Center, Republic Activities Building, or the Republic Senior Friendship Center.
Facilities should be used for the function for which they were listed and intended.
User shall ensure that prior approval is received before signs or banners are erected, and that they not deface city property.
User shall ensure that the representative specified in the agreement is present at the scheduled event.
User shall ensure no unauthorized third party will be permitted to use the facility or any portion thereof.
User shall ensure that children will be properly supervised with adequate adult supervision.
User shall ensure the number of attendees does not exceed the authorized capacity.
User shall ensure that participants are in only the requested area.
User shall ensure that all activities are orderly and lawful.
User shall observe the time limits that were agreed upon.
No Call/No Show/No Pay Please see front of document for policy and initial box.
User shall agree to be responsible for and reimburse the Parks & Recreation Department cost associated with any repairs to, or replacement of , any property or equipment damaged,
stolen or lost caused by any member of the renting organization, except for normal wear and tear as deemed appropriate by the Parks & Recreation Director.
User shall agree to hold harmless and indemnify the City of Republic with respect to any loss, injury or damage because of negligence of the user, user’s participants, guests, groups or
agents, including damage to property of the City of Republic or property for which the City is responsible.
User shall comply with all federal, state and local laws, regulations and licensing requirements.
4. Preemption Privilege
Out of necessity, the City of Republic must retain the right to cancel scheduled use of facilities.
5. Liability
Any individual or organization authorized to use a public facility is responsible and liable for any damage or loss to the facility during the use of the facility. In addition, the individual or
organization must either carry liability insurance, or agree to stand responsible for any liability claims made against the city for any incident that occurred in connection with the use of
a public facility.
Any responsible party found violating any of the above rules and regulations will be subject to a ban of all future rentals for a period of one year from the rental date.
Individuals must be at least 18 years of age or older to sign as the responsible party.