Chesterfield Township Parks Pavilion, Tents & Building Rental Form
Staff Only
Pavilion Rental: ________
Fee: ________
Account Number: 545-000-653
Tent Rental: ________
Fee: ________
Account Number: 545-000-653
Building Rental: ________
Fee: ________
Account Number: 545-000-653
Security Deposit: ________
Fee: ________
Account Number: 701-000-285
Extra Tables: ________
Fee: ________
Account Number: 545-000-642
Pre-Paid Parking: ________
Fee: ________
Account Number: 545-000-652
TOTAL DUE: ___________ DATE: ___________CASH: _________CHECK: _________CREDIT: ________ TREASURER’S OFFICE: ________
Please make checks payable to: Chesterfield Twp. Visa & MasterCard accepted on-site only
PLEASE PRESS FIRMLY
First Name: ____________________________________ Last Name: ___________________________________________
Organization: _______________________________________________________________________________________
Address: _______________________________ City: __________________________ State: _____ Zip: _________
Home #:____________________Cell #: ___________________Work #: ___________________
Drivers License #: ______________________________________________________ D.O.B: _________________
A security deposit of $100.00 is required for all rentals. All rental fees and security deposits must be paid to guarantee reservation.
Security deposits will be returned via U.S. mail three to four weeks after the scheduled rental date.
Rental Date: ________________ Day: ____________ Event: _________________________ Number of Guests: ________
* RENTAL FEES:
RENTAL TYPE
LOCATION
FEE
Pavilion
Pavilion A (Holds 8 tables)
Closest to the parking lot
$150
Pavilion B (Holds 8 tables)
Closest to the playground
$150
Pavilion C (Holds 6 tables)
Closest to horseshoes/ w/restrooms $150
Pavilion D (Holds 8 tables)
Closest to the water
$150