Facility Request Form (Page 2 of 2) in pdf

Facility Request Form Page 2

Office Use Only: approved_________________ Date___________ Due________

APPENDIX A-1

Parks and Recreation Department

Hebron, CT

Hold Harmless Agreement

I, ______________________________, a resident of ________________, Connecticut,

and residing at ______________________________________________, hereby apply on behalf

of myself or the Organization identified below (the “User”), for a permit to use Town property.

The Town property to be used and the date(s) of use are as follows: Property:

_________________________________________________; Date(s) of

Use:______________________________________.

Complete only if application is for an Organization:

I am applying for this permit on behalf of __________________________________ (the

“Organization”), of which I am __________________________. I hereby represent that I have

been authorized by the Organization to make this application and to bind the Organization to this

Hold Harmless Agreement.

In exchange for the consideration given by the Town of Hebron in permitting the use of Town

property, the undersigned User agrees that it shall not hold the Town of Hebron responsible for

any claims or injuries of any nature whatsoever that may arise out of the use of the property. The

undersigned User further agrees to indemnify and hold the Town harmless from any and all

claims, losses, damages, judgments, costs, settlements, fines, penalties, and expenses (including

legal fees) that the Town may incur, directly or indirectly, as the result of the use of the property,

including with limitation claims, losses, etc. that may result from a claim by the User or a

member of the User or by a third party.

If User is an Individual:

______________________________________

______________________

Signature of Applicant

Date of Application

If User is an Organization:

_______________________________________

_______________________

Print Name of Organization

Date of Application

By:_______________________________

Its: _______________________________

Facility Request Form Page 2