Event Name
Date(s) Time of
Event Event
Location of
(facility name/address):
Event Name
Coordinator Address
Information Phone/Cell
Will food be served on-site? Yes No
If yes, please check with the
Health Department for
food service regulations.
Will children’s inflatable Yes No
bounce units be provided
If yes, please check with the
Zoning Office for regulations.
Please briefly describe the activities planned for this event (for review by Public Safety and Law
Enforcement Officials, Health Department Officials, School Administration and County Administration).
Scheduled Rain Date
Campbell County Administration
P.O. Box 100
Rustburg, VA 24588
(434) 332-9525; 283-9525 or 592-9525
Special Entertainment/Event Permit
(for events on school or County-owned properties)
Please carefully
read the liability
provided on the
back this form prior
to submittal.
Print Form
12:00 a.m.
12:00 a.m.
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
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/or an electronic version (via e-mail or on disk) 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)
School Official/Principal
Director of Recreation
Health Department Official
County Administrator
School-Related Special Entertainment Permit
Staff Review and Approvals
For internal purposes only Event Name Event Date
Date Signature
Please note: A copy of the event packet and approval form will be submitted to the Campbell County Sheriff’s
Department and the Campbell County Department of Public Safety for review. Applicants may be
contacted by respective officials if there are questions pertaining to event plans or modifications required to
ensure citizen safety.
Special Notes:
Print Form