Administrative Directive No. 45
Page 1 of 4
Attachment “A”
CITY OF GREENACRES
FACILITY RENTAL APPLICATION
Facility requested______________________________________________________________________
Name of organization or party____________________________________________________________
Contact Person________________________________ Day Phone_____________ Eve Phone__________
Address______________________________________________________________________________
Second Contact Person_________________________ Day Phone______________ Eve Phone_________
Date/Time of Event__________________________ Description _________________________________
Special Instruction ______________________________________________________________________
# of people___________ Admission Charge Yes No
Food/Drinks Yes No
RELEASE WAIVER
I, the undersigned, intending to be legally bound, do hereby for myself, family,
guardians, child/children, heirs, executors and administrators, waive and release any and
all rights and claims for damages, which I/we may have against the City of Greenacres,
its representatives, successors and employers for any injuries which I/we may suffer in
connection with my/our use of this facility. I have read the above and understand the
rules and regulations of the City of Greenacres that have been made available to me.
I understand that if any of these rules are violated it will result in forfeiture of my
security deposit.
Applicant’s signature________________________________ Date__________________
Witness signature___________________________________ Date__________________
FOR CITY USE ONLY
FEES:
Facility $ __________
Tax
$____________ TOTAL $_______________
Check #_______ Amount ________ Cash ____________ Receipt #_____________ Date ____________
Name on Check _______________________________________________________________________
Security Deposit ______________ Check #_______________ Cash_____________ Date