Application to Schedule Peace Dale Library Meeting 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")

 

___________________________________________________________

 

___________________________________________________________

 

___________________________________________________________

 

Purpose of Meeting____________________________________________

 

___________________________________________________________

 

Will you want access to the Kitchen: ___Yes ___No

Will you want access to the Lavatory: ___Yes ___No

 

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 Meeting Room.

 

_____________________________________________

Signature

 

______________________________________________

Title

 

Name and Telephone Number of person responsible for keys (if different from Applicant)

 

_________________________________________________

 

Additional Notes:

 

For Library Use Only:

Approved by:_______________

Date_____________________