CITY OF COLUMBUS
2007 SENIOR CENTER RENTAL APPLICATION
Columbus Area Senior Center
125 N. Dickason Boulevard
Columbus, WI 53925
(920) 623-5918
The undersigned individual or group hereby makes application to rent the Columbus Area Senior Center facility
according to the requirements and conditions set forth.
NAME OF USER/ORGANIZATION/AGENT:_________________________________________________
CONTACT PERSON (if different than above):_________________________________________________
ADDRESS:_______________________________________________________________________________
CITY/STATE/ZIP:_________________________________________________________________________
PHONE NUMBER:________________________________________________________________________
DATE & TIME FACILITY REQUESTED:____________________________________________________
PURPOSE:________________________________________________________________________________
APPROXIMATE NUMBER OF PEOPLE AT EVENT:__________________________________________
CIRCLE THE APPROPRIATE RENTAL CATEGORY:
Businesses&Private Groups
Meeting Room Only
$50
(plus $30 security deposit)
Kitchen & Meeting Room
$75 (plus $30 security deposit)
Non-Profit Organizations (must provide copy of non-profit certification)
Annual Usage Fee for Meeting Room
Use of Kitchen $15/use
1-6 times per year $20
(plus $30 security deposit)
7-12 times per year $40
(plus $30 security deposit)
13-24 times per year $60
(plus $30 security deposit)
25+ times per year $100 (plus $30 security deposit)
RELEASE OF LIABILITY
In consideration of the permission granted to ______________________________(user) to use the
requested city property, the undersigned discharges and releases the City of Columbus, Wisconsin, from
all claims, demands or liability whatsoever which we may now have or hereafter have, as a result of use
of the premises on __________________________(date).
Sign