City of Falls Church • Recreation & Parks Department • 223 Little Falls Street • Falls Church, VA 22046
703-248-5027 • Fax 703-536-8150 • recreation@fallschurchva.gov
APPLICATION FOR USE OF
FACILITIES AND EQUIPMENT
1) Today’s Date____________________________________________
2) Organization____________________________________________
3) Applicant Name__________________________________________
4) Address________________________________________________
_______________________________________________________
5) Phone (H) ________________ (W)___________________________
6) E-Mail__________________________________________________
7) Person in Charge (if other than applicant)
Name___________________________________
Phone _________________________________________________
8) Activity Type____________________________________________
9) Date(s) of Use___________________________________________
_______________________________________________________
10) Time Rental Begins___________Time Rental Ends______________
11) Number of people expected? Min.___________ Max.___________
12) Is organization a civic or community organization? YES □ NO □
13) Does user collect fees? YES □ NO □
Admissions: Adults $______________ Youth $________________
14) Proceeds will be used for? _________________________________
15) Will food and beverages be served? YES □ NO □
Requests for alcohol can only be made by residents and only for the
Cherry Hill Shelter or Mr. Brown’s Park. A written request must
accompany the application and is subject to the Director’s approval.
An ABC License is required.
16) Space Requested (fee varies upon space selected):
□ Art Room □ Mr. Brown’s Park
□ Community Room □ Cherry Hill Shelter
□ Senior Center 1 (Left) □ Roberts Park Shelter
□ Senior Center 2 (Right) □ Madison Park Shelter
□ Full Senior Center □ Berman Park Shelter
□ Teen Center □ Full Gym
□ Party in the Gym Package
The Party in the Gym package includes use of half of the gym and a
party room (Art Room or half Senior Center) for 3 hours.
17) Is room setup needed? YES □ NO □
If yes, please detail needs here or attach a separate diagram:
18) Equipment Requested: (enter quantity where applicable)
□ Tables - If so, how many? __________
□ Chairs - If so, how many? __________
□ Podium □ Microphone
□ Other (Specify) ______________________________
* Security Deposit will be fully refunded at the end of the reservation if
the space is left in the same condition as it was found.
The undersigned certifies that he/she is familiar with the Falls Church
Recreation & Parks Department policies and regulations as stated on the
accompanying pages of the agreement, and that these shall be enforced
as well as honored by the using group. The undersigned further certifies
that he/she is the authorized representative to act for and accept the
responsibility for the organization.
________________________________________________________
Signature of Representative
PERMIT NOT TRANSFERABLE
Type of Rental:
□ Civic – Resident □ Civic – Non-Resident
□ Private Event - Resident □ Private Event - Non-Resident
□ For-Profit – Resident □ For-Profit – Non-Resident
Room Rental Fee: Personnel Fees:
No. of Hours_________ Supervisory Fee: $_________
No. of Meetings_________ Maintenance Fee: $_________
Total $___________ Other Fees $___________
Total $___________
Total Balance Due $___________
Security Deposit $ _____________
Space Assigned_______________________________________________
RECREATION & PARKS DEPARTMENT
APPROVED □ DENIED □
________________________________________________
Director of Recreation & Parks
Comments__________________________________________________
___________________________________________________________
___________________________________________________________
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