Application to Schedule the Peace Dale Library Conference Room

Today's date _________________________________________

Organization Represented_______________________________

Applicant's Name______________________________________

Mailing Address_______________________________________

City/Town, State, Zip ___________________________________

Telephone(s)_________________________________________

Fax Number (optional)___________________________________

E-mail Address (optional)________________________________

Specific Dates and Times requested (please provide all actual dates you are requesting; for example: "Wednesdays, June 1, 8, 15, 22, 29 from 3-4 PM")

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Purpose(s) of Meeting_____________________________________________________

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I, (Name)_______________________________________, in consideration of use of the South Kingstown Public Library ("Facility"), do hereby on behalf of myself, my successors, heirs, and assigns, remise, release, and forever discharge the Town of South Kingstown and the South Kingstown Public Library Trustees and staff (employees ahd volunteers), their successors and assigns of and from any and all accounts, reckonings, covenants, contracts, controversies, agreements, promises, damages, judgments, executions, claims, and demands whatsoever, in law, or in equity, which I may have, or which I may have in the future, as a result of my use of the Facility.

I will be fully responsible for adhering to the documented policies and procedures of the South Kingstown Public Library's Peace Dale Conference Room.

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Signature

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Title

Additional Notes:

For Library Use Only:

Approved by:_______________

Date_____________________