North irwin playground



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NORTH IRWIN PLAYGROUND

PAVILLION USE APPLICATION


DATE___________________________
NAME____________________________________________________
ADDRESS________________________________________________
PHONE # _______________________ N.I. RESIDENT?________
EMPLOYED BY: ________________________________________________
ADDRESS______________________________________________________
DATE REQUESTED: ___________________
GROUP/ORGANIZATION NAME ______________________________________
REASON FOR REQUEST: ___________________________________________________________
ARRIVAL/DEPARTING TIME: ___________________# OF PEOPLE_______

UNDERSTAND RULES/REGULATIONS? _________


SIGNATURE OF APPLICANT_________________________________________
ACCEPTED BY: ____________________ DATE__________________
RESIDENT COST: $40.00____________ CHECK NO.___________
NON-RESIDENT COST $50_______________ CHECK NO.__________
CLEAN-UP DEPOSIT $50.00_____________ CHECK NO.___________

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