HomeMy WebLinkAboutFacility Use Applicationt
Public Works Department
2100 Hoover Avenue National City, CA 91950
(619) 336-4580 Fax (619) 336-4594
w w_nationalcitvca.gov
Applicant Information
(Please be sure to print in blue or black ink)
Today's Date: in
*e& '1C01(.\ g-
l�Iame: Organization:
Address: WO tZ•
City/ State/ Zip: Os`i6o4A 6A1 t a1`�
Phone: tea' 4:14- 0 Contact:
Field / Facility / Park Requested
Please check all that apply:
El Toyon Park V Kimball Park Las Palmas Park
Sweetwater Heights Park Camacho Gym Pool
El Toyon Rec. Ctr. Kimball Rec. Ctr Camacho Rec. Ctr
Casa De Salud Kimball Senior Centre Nutrition Center
tZ,• Audio & Visual Equipment Required? (Please Specify)
C`'s'oS ekAg fi4,q_ Nfrno. .
cavity
Please circle appropriate activity:
Astrojump Meeting Room Athletic Field rental* Baseball* FootbaII*
Softball* Volleyball* Basketball* Tennis* Soccer* Picnic
Swimming
Other
*If reserved for league play, you must submit a team roster with addresses within. 10 working days.
Amount: Date Paid: / / Initials:
Field / Facility Information
Dates requested: CC. / l /20 l2 to I I / I5 /20 rL 044" i4¢ �
Days of the Week and Hours recuested
Days
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday .
Sunday
From:
1.�in
a'z ny)
To :
no--,
4 +
lq n,
Total
number of participants at your event % of participants National City residents
Field / Facility Request Form Checklist
Requesting Organization: C. ,0
Name: -Oa�Qrm0.
Dater / e-g
Please initial all sections of this checklist:
f f Field / Facility Request Form V, Hold Harmless / Indemnification
Pf Current Insurance Certificate of Current Organization's Bylaws
Current Audited Financial Statement Preliminary Roster Data
Current Roster Data E4 Received Copy of City Council Policy 801
(By tad Game of Season)
Public Property Use Hold Harmless and Indemnification Agreements
Person's requesting use of City property, facilities or personal are required to provide aminimum of$1,000,000
Combined single limit insurance for bodily injury and property damage which include the city, it's officials, agents
And employees named as additional insured and to sign the Hold Harmless Agreement, Certificate of Insurance must be attached
to this Permit.
As a condition of the issuance of a temporary use permit to conduct its activities on public or private property, the undersigned
hereby agree(s) to defend, indemnify and hold harmless the.City Of National City and its officers, employees and agents from
and against any and all claims, demands, costs, losses, liability, or damages for any personal injury, death or property damage, or
both , or any litigation and other liability, including attorneys fees and the cost of litigation, arising out of or related to the use of
public property or to the activity taken under the permit by the permites or its agents, employees or contractors.
I have read and completed the above form to the best of my knowledge
Signature: J Date: 1 / /Zc.t`i
Department of Public Works Staff Use Only
Verified By: PRINT ,rt'
NAME•tt,,
_ "
Signature. \
FOR DEPARTMENT U�'`\j�L1'
Date: ? / i2 4
PARK DIVISION APPROVAL: YES NO DATE: l / /
PUBLIC WORKS APPROVAL: YES NO DATE: /. /
NOTE; ALCOHOLIC BEVERAGES / SMOKING BANNED IN
ALL FIELDS / FACILITIES/ PARK
Revised 6/28/11
California Football Alliance (CFA) / National City Bears
140 W 16th Street National City, CA 91950
Tel: (619) 474-5300
Email: ncbears@nationalcitybears.com
Games:
1•
20-Oct-12
vs Southbay Spartans
Last Home Game Regular Season
Set Up: 12pm / KO: 5pm / PGS:7pm
3-Nov-12
Play Offs
Practices:
10-Nov-12 Division Championship
i
Set Up: 12pm / KO: 6:30pm
Division Play Offs
!Set Up: 12pm / KO: 6:30pm
Tuesdays & Thursdays
7:00pm - 9:00pm (2hrs)
Oct. 2,4,9,11,16,18,23,25,30
Nov. 1,6,8,13,15
Championship Game
Nov 17th @ Whittier College
G000 ... National City Bears !!!
Tel: (619) 474-5300
LEnnail: ncbears@nationalcitybears.com
www.nationakitvbears.com