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2. Section I
4. Requesting Organization
5. Date
   Date
7. Name of Application
8. Phone Number
9. Email
11. Physical Address
12. Mailing Address
14. City
15. State
16. Zip Code
20. Section II
22. Requested Facility / Specific Area(s)

    1. Cafeteria
    2. Craft Room

    1. Gymnasium
    2. Kitchen

    1. Meeting Room
23. Date Desired for Activity
    Date Desired for Activity Start Date

    —

    Date Desired for Activity End Date
25. What time do you need to enter the building?
    What time do you need to enter the building? Start Time

    —

    What time do you need to enter the building? End Time
26. Time of Activity
    Time of Activity Start Time

    —

    Time of Activity End Time
28. Proposed Use
30. Number of Adults Attending
31. Number of Children Attending
32. Number of Teens Attending
34. Equipment Request
35. Layout of Chairs / Tables (Attach Drawing)
37. Will refreshments be served?

    1. Yes

    1. No
38. Board of Health approval needed?

    1. Yes

    1. No
40. If Merchandise Is to Be Sold, Please Describe (Percentage Profit of Items to Be Negotiated)
42. By signing this application, the person whose signature appears below signifies that he/she is personally, financially responsible for their group, will see that the facilities and equipment are not misused, that groups have proper adult supervision, that properties are used in conformity with policies established by the Town of Ipswich, and that any damages and/or loss whatsoever as a result of the group’s use of properties will be compensated in full by the responsible person, upon demand.
    
    It is hereby understood by the responsible person signing this application that any town activities have absolute priority for use of any portion of the building, even if an outside group (e.g., the applicant) has requested the use of a portion of the building for several weeks. Any Town activity whatsoever that may be subsequently scheduled shall have absolute priority for use of the building and/or use of any of its rooms.
    
    The Town of Ipswich disclaims liability for loss or damage to personal property or personal injury, and the applicant individually and on behalf of each member of his/her group agrees to release and hold harmless the Town of Ipswich officials and employees and not to sue any of the same for any such liability or loss.
    
    I hereby personally accept on behalf of the sponsoring organization all financial responsibility for any and all damages to equipment and/or facilities and all resulting cost of any nature whatsoever.
44. Responsible Person Signature (Applicant)*
46. Approved By (Town Official Signature)
47. Date
    Date
51. Section III
53. Who is using the space?

    1. Local For Profit Group
    2. Local Non-Profit Group

    1. Non-Local For Profit Group
    2. Non-Local Non-Profit Group

    1. Town Department / Committee
55. Rental Fee
56. Personnel
57. Police
58. Other
60. Custodial Time Required for Setup, at Overtime Rate
61. Custodial Time Required for Cleanup, at Overtime Rate
63. Comments
    Additional instructions and layout map may be attached.
64. Upload Supporting Documents
66. Total Anticipated Charges
    Check or money order made out to the Town of Ipswich.
68. Approval
    Site Supervisor
69. Date
    Date
71. Equipment Use Approved

    1. Yes

    1. No
72. Merchandise Sale Approved

    1. Yes

    1. No
73. Refreshments Approved

    1. Yes

    1. No
75. Other Comments / Conditions of Use
Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit

* indicates a required field