Liability Insurance Information
A certificate of insurance for this event (if applicable) must be presented to Campbell County
Administration no later than fifteen (15) calendar days prior to the start date of the event. If the
information requested below is not available when this application is submitted, it can be added
later, but not later than the fifteen (15) day deadline previously noted.
Indemnity Agreement
In consideration for Campbell County granting the undersigned Event Organizer representative
permission to hold the proposed event and to display, sell, or offer for sale wares, services and/or food or
merchandise within the perimeters of their event venue, the undersigned agrees to assume the defense and
indemnify and save harmless the County, its employees, offices and agents against any and all claims, liabilities,
judgments, costs, causes of action, damages, expenses and shall pay all attorney’s fees, court costs and other
costs incurred in defending such claims, which may accrue against, be charged to, be recovered from, or sought
to be removed from the County, its employees, officers and agents by reason of or on account of any personal
injury or death or damage to property arising from the undersigned’s event and associated activities, if such
personal injury or death or damage of property is caused by the acts or omissions or negligence of the
undersigned, or the undersigned’s employees and agents or by such acts, omissions or negligence of any other
person subject to the undersigned’s control. The County, its employees, officers and agents shall not have to
give the undersigned any specific types of notices of such claims.
Affidavit of Applicant
I certify that the information contained in this Special Event Application is true and correct to the best of my
knowledge and belief, that I understand, and agree to abide by all regulations, provisions, and rules governing
Special Events as set forth by Campbell County. I certify that I understand that this application is made subject
to the rules and regulations established by the Campbell Board of Supervisors. I agree to abide by these rules
and further certify that, on behalf of the organization, I am authorized to commit that organization, and therefore
agree to be financially responsible for any costs and fees that may be incurred by or on behalf of the Event to
Campbell County. I grant permission for county officials to access the property at any time to enforce permit
compliance.
A signed hard copy of the Indemnity Agreement and Affidavit of Applicant portions of the
Special Entertainment/Event Permit Application must be provided to the County before an application will be
considered fully executed. Submit one hard copy (and an electronic version, if possible) of this Special
Entertainment permit application to Campbell County Administration, c/o Cathy Moore, Clerk of the Board of
Supervisors, P.O. Box 100, Rustburg, VA 242588; chmoore@campbellcountyva.gov
_____________________________________ _______________________
Event Coordinator/Responsible Event Representative Date
(Print Name)
_____________________________________
Signature
As the property owner, I hereby acknowledge and give consent for the event described herein to proceed on the
indicated properties with full understanding of any liability and responsibility associated with all planned
activities.
_____________________________________ _______________________
Property Owner (Print Name) Date
_____________________________________
Signature
