Will additional picnic tables, grills, porta-potties or dumpsters be required? ____ Yes _____ No
If yes, provide details - ________________________________________________________________
Will the event involve vendors? _______Yes _____ No
If yes, attach a separate listing of all vendors with contact information.
Will first-aid, fire and rescue services, or other safety and security measures be needed?
_____ Yes _____ No If yes, attach a separate listing with details/contact information
Are any additional permits for any other government agencies required? _________
If yes, list all agencies, contact information and type of permits separately.
Are there any special requests or circumstances (i.e. inflatable bounce houses, toys, slides,
amplified music, banners, signs, etc)? ______Yes _____ No
If yes, provide details - ________________________________________________________________
____________________________________________________________________________________
Contact person and means of contact during Event _____________________________________
Attachments:
( ) Parking/Traffic Plan ( ) Safety & Security Plan ( ) Map/Site Plan
( ) Request for Other Services ( ) Certificate of Insurance ( ) Vendor Lists
( ) Other Agency Permits ( ) Non-Profit Verification
*************************************************************************************
Approval of this application will reserve for the applicant the requested event date and place, providing all
requirements outlined by the Special Event Policy are met. Once approved, the sponsor shall assume full
responsibility for compliance with all conditions, fees and charges and further agrees to pay any cost associated with
damage to Conservation Board property, cleanup, or any other additional expense caused by this event, over and
above the security deposit. I have a copy of the Special Events Policy, and will supply the required insurance
certificate, permits and other assessed fees (deposit and fees) at least 30 days prior to the event. I understand that
failure to provide any of these items is grounds for cancellation of the event. (See Special Events Policy)
Applicant agrees to leave the used site in the same condition as found, cleaning up all litter and debris after the
event. Applicant is responsible for any damages to county property during the event either by participants or
spectators. Applicant agrees to abide by all state laws and Scott County Conservation Board rules and regulations.
The undersigned applicant for a special event permit understands and agrees that neither the Scott County
Conservation Board nor Scott County will be responsible for any injury to persons or damage to property arising out
of or incident to the activities which are the subject of this application. The undersigned applicant agrees by the
execution hereof to indemnify and hold harmless the Scott County Conservation Board against all liabilities, costs,
and expenses which may arise in consequence of the granting of this permit.
The undersigned has full authority to represent the sponsoring organization:
Applicant's Signature _____________________________________________ Date __________________________
Park Manager Coordination ________________________________________ Date __________________________
RETURN COMPLETED APPLICATION TO:
Scott County Conservation Board
14910 110
th
Avenue
Davenport, Iowa 52804
(563) 328–3280
www.scottcountyiowa.com/conservation
