community center rules and regulations · 130 samson dale avenue· west haverstraw, new york 10993...
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130 SAMSON DALE AVENUE· WEST HAVERSTRAW, NEW YORK 10993845-947-2800· FAX 845-947-1560
COMMUNITY CENTERRULES AND REGULATIONS
1. All village laws and ordinances will be strictly enforced.
2. The use of alcoholic beverages and/or drugs are prohibited.
3. No smoking allowed in building.
4. Adult supervision must be provided at all times (ratio 2 adults to every 15 children,at least 2 adults at all times).
5. Putting up decorations or moving of furniture is prohibited unless prior permissionis granted.
6. Items may not be sold, exhibited or displayed without prior permission.
7. Applicant will be responsible for the cost of repair of any damage incurred duringthe use of this facility.
8. Building must be left in the same condition in which it was found. Applicant will beresponsible for any janitorial charges needed to restore the center to its conditionprior to use.
9. The Village of West Haverstraw will not be responsible for any property left, lost orstolen at Center.
10. Any malfunction or safety hazard must be reported immediately.
11. The approval of this application does not permit the applicant to lease or allow anyother organization or persons to use this facility in its name or for its time slot.
12. Cancellations must be communicated as soon as possible, and no later than 3:45pm Monday through Friday. Excessive cancellations may result in loss of privi-leges.
13. Group may not be left unattended at any time. Responsible person must be pres-ent prior to use and remain until all children have left premises.
Date: _Signature of Applicant
130 SAMSONDALE AVENUE -WEST HAVERSTRAW, NEW YORK 10993845-947-2800 - FAX 845-947-1560
APPLICATION FOR USE OF THE COMMUNITY CENTERPLEASE FILL OUT COMPLETELY. INCOMPLETE APPLICATIONS WILL BE RETURNED.
o FALL 0 WINTER 0 SPRING 0 SUMMER NO: DATE: _
1. Name of Group/Organization _
3. Dates requested: _
2. Room to be used: o Gym o Community Room 0 Board Room
Time: From AM / PM to AM / PM
4. Authorized representative of Group/Organization
Name . ----"- _
Address _
No _
5. Describe nature of activity _
6. Number of participants __ .. Number of adults (ratio 2:15) (NOTE: At least 2 adults at all times)
7. Any special ser~ces requested? _
8. Will admission be charged? Yes _
9. Will any items be sold? Yes _
10. How will funds be used? _
Phone: _
No _
Pager _
Amount $ _
o Food 0 Non-Food
11. Name of Insurance Company _
Policy Number _
PLEASE NOTE: Certificate of Insurance must accompany application. Minimum required insurance is onemillion dollars. Certificate must (1) name Village as additional insured and (2) provide for 30 days notice ofcancellation or termination to village.
The undersigned hereby certifies that he/she has read, fully understands, and agrees to abide with theregulations and conditions concerning this application, and will comply with them.
Date of Application _ x . _Sign Here (Authorized Representative of Group/Organization)
THE USE OF THE COMMUNITY CENTER IS SECONDARY TO THE NEEDS OF THE VILLAGE OF WESTHAVERSTRAW AND MAY BE CANCELLED TEMPORARILY OR PERMANENTLY, IF NEEDED.
DO NOT WRITEBELOWTHISUNE- FOR CoI\11MUr\iITy.~CE'NTEFfOSE dNLY;, , ..';, ' .. : ;' '. ' I "," - :- .. "', ....•" •.:,' • :-- ,.- -f ' "' :' " , _.. ' ~ ..• '." "
o APPROVED o DISAPPROVED
DATE APPROVED _ SIGNATURE _
130 SAMSON DALE AVENUE· WEST HAVERSTRAW, NEW YORK 10993845-947-2800 • FAX 845-947-1560
APPLICATION FOR USE OF THE PECKS POND RECREATIONAL FACiliTIESPLEASE FILL OUT COMPLETELY. INCOMPLETE APPLICATIONS WILL BE RETURNED.
o FALL 0 WINTER 0 SPRING 0 SUMMER No. _ Date _
2. Facility to be used: 0 Hardball Field 0 Softball Field 0 Pavilion 0 Rink 0 Parking Lot
o Other _./3. Dates requested Time: From AM/PM to AM/PM
4. Authorized representative of Group/Organization
Name _
Address _
Phone Cell Phone _
5. Describe nature of activity _
6. Number of participants Number of adults (ratio 2:15) (NOTE: At least 2 adults at all times)
7. Will admission be charged? 0 Yes 0 No Amount $ _
8. Will any items be sold? o Yes 0 No o Food 0 Non-Food
9. How will funds be used? _
Policy Number _
PLEASE NOTE: Certificate of Insurance must accompany application. Minimum required insurance is one milliondollars. Certificate must (1) name Village as addit"onal insured and (2) provide for 30 days notice of cancellation ortermination to Village.
The undersigned hereby certifies that he/she has read, fully understands, and agrees to abide with the regulations and conditionsconcerning this application, and will comply with them.
Date of Application _ x _Sign Here (Authorized Representative of Group/Organization)
THE USE OFTHE PECKS POND FACILITIES IS SECONDARY TO THE NEEDS OFTHE VILLAGE OF WEST HAVERSTRAWAND MAY BE CANCELLED TEMPORARILY OR PERMANENTLY, IF NEEDED.
DO NOT WRITE BELOW THIS LINEo Approved
Date Approved _
o Disapproved
Signature
130 SAMSONDALE AVENUEWEST HAVERSTRAW, NEW YORK 10993
845-947-2800 • FAX 845-947-1560
ORGANIZATION INFORMATION SHEET
Name of Organization _
Tax ID# _
Are you a not-for-profit organization? 0 Yes 0 No
Number of Village of West Haverstrawresidents in organization? _
ORGANIZATION OFFICERS:
PRESIDENT Name _
Address _
Home Phone Work Phone _
VICE PRES. Name _
Address _
Home Phone Work Phone _
SECRETARY Name _
Address _
Home Phone Work Phone _
TREASURER Name _
Address _
Home Phone Work Phone _
130 SAMSON DALE AVENUEWEST HAVERSTRAW, NEW YORK 10993
845-947-2800· FAX 845-947-1560
HOLD HARMLESS(USE OF FACILITIES)
(GROUP I ORGANIZATION NAME)
does hereby convenant and agree to defend, indemnify and hold harmless
the Village of West Haverstraw from and against any and all liability, loss,
damages, claims or actions (including costs and attorneys' fees) for bodily
injury and/or property damage, to the extent permissible by law, arising out
of or in connection with actual or proposed use of the Village of West
Haverstraw Community Center property, facilities and/or services by:
(GROUP I ORGANIZATION NAME)
and/or activities, functions, events, affairs or proceedings of
(GROUP I ORGANIZATION NAME)
SIGNATURE OF AUTHORIZED REPRESENTATIVEOR GROUP I ORGANIZATION
DATE