Home Phone # ( ) _____-______ Cell # ( ) _____-______ Email ... Time ______:______a.m. / p.m. TO ______:______a.m. / p.m
Edwardsville Parks and Recreation 118 Hillsboro Avenue, P.O. Box 407, Edwardsville, IL 62025 Special Event Permit Application # __________ This application must be filled out in entirety for your reservation to be considered. All applications are considered on a first come first serve basis, with City sponsored events taking priority. All fees required shall apply to defer any utility, maintenance, repair and personnel costs incurred as a result of said permitted use. FEES ARE NON- REFUNDABLE. The Recreation, Arts, & Special Events Board reserves the right to reject any application and to waive any fee required. Applicant must complete the following application and return it with proper fees at least two (2) weeks prior to requested use. Community Events must be received for review ninety (90) days prior to the requested event date.
Applicant Name ______________________________________ Age ______ Date of Birth ______/______/________ *Organization Name __________________________________ IRS 501(c) Tax Exempt # _______________________ Address ____________________________________________ City/State/Zip ________________________________ Home Phone # (
) _____-_______ Cell # (
) _____-_______ Email __________________________________
Nature of Event _____________________________________ Date Requested for Event ______/______/________ Total Reservation Time ______:______a.m. / p.m. TO ______:______a.m. / p.m. (include set up and tear down) Actual Event Time ______:______a.m. / p.m. TO ______:______ a.m. / p.m.
Expected # of attendees _______
* All organizations are required to provide a copy of insurance naming the City of Edwardsville as additional insured.
Park/Facility Requested: Please check appropriate park or facility you wish to reserve. Non-resident fees apply to all applicants outside of Edwardsville city limits. This fee must be included for your application to be considered.
Joe Glik Park: Rotary Pavilion
______ Resident: $100 ______ Non-Resident: $150
Joe Glik Park: Gugger Pavilion
______ Resident: $60 ______ Non-Resident: $100
Leclaire Lake: Madison Ave. Pavilion
______ Resident: $60 ______ Non-Resident: $100
Leclaire Lake: Gazebo
______ Resident: $60 ______ Non-Resident: $100
City Park Bandstand
______ Resident: $60 ______ Non-Resident: $100
Leon Corlew Park: Playground Pavilion ______ Resident: $100 ______ Non-Resident: $150 ~ (10:00am-3:00pm or 4:00pm-9:00pm) ~ FOR SPLASH PAD RENTALS PLEASE USE LEON CORLEW PARK SPLASH PAD RENTAL FORM Other: ___________________________________________________ (please call Parks staff member for pricing) Requested Event Needs-Please check ALL that apply. _____ Picnic Reservation
_____ Bandstand Use
_____ Charity Event
_____ Wedding
_____ Restrooms
_____ Electricity
_____ Alcohol Served
_____ Cooking/Food Served
_____ Litter Receptacles
_____ Lake Use
_____ Security Fence
_____Decorations/Sign/Display
_____ Amplified Sound
_____ Fireworks
_____ Tent Placement
_____ Carnival Rides
_____ Inflatable Rides
Other (Specify) __________________________________________________________
Edwardsville Parks and Recreation 118 Hillsboro Avenue, P.O. Box 407, Edwardsville, IL 62025
Special Event Permit Application # __________ (Pg 2) HOLD HARMLESS AGREEMENT THE APPLICANT IS RESPONSIBLE FOR INFORMING THE GROUPS MEMBERS OF THEIR DUTIES AND RESPONSIBILITIES UNDER POLICIES AND PROCEDURES. 1. It is understood and agreed that the City, it's Mayor, City Council, R.A.S.E. Board, employees, volunteers, and agents shall be held harmless against all claims, damages, loss or expenses including attorney's fees arising out of or resulting from the use of this facility. 2. Each group shall be fully responsible for the physical condition in which they leave the facility. The expenses resulting from any damage or undue maintenance shall be charged to the applicant and taken from deposits. Failure to meet any obligations beyond deposit amount within thirty (30) days of billing will be cause for cancellation of future privileges and for legal action including all costs incurred by the City for collection. 3. Alcohol is prohibited on all park property. 4. I have read, understand, and agree to comply with all the rules, regulations, policies, and fee schedules, as set forth by the City of Edwardsville. I further attest that I will be personally responsible for repair or damage to equipment, the facilities, and grounds or for replacement of stolen equipment. 5. I agree to be responsible for the conduct of our group in and about the facilities in use, for the control and containment of noise, group participants, litter and damage beyond ordinary wear and tear, which may occur while we are occupying the premises. I further agree that use of the requested facilities shall be in accordance with Policies and Procedures, local ordinances, and all valid laws of the State of Illinois. *____ I am over 21 years of age. *____ I agree to adhere to all policies set forth by the City of Edwardsville. *____ I acknowledge that my deposit may be kept to pay for damage caused by group or to clean facility after use. *____ All information, to the best of my knowledge, provided on this form is truthful. * Applicant must initial all statements above. Applicant Signature _______________________________
Today’s Date _____/_____/_____
Note: The person applying for permit shall be responsible for any and all damages to personal and public property which may occur as a result of the requested use. Permit is valid only for dates and times listed, and must be posted on site during the event.
If paying by check: Make checks payable to Edwardsville Parks & Recreation Amount Due $ ________ If paying by credit card: Amount Due $ ________ + $4 if paying by credit card. Total Amount Charged to Card $ ___________ _____ Visa
_____ MasterCard
Card # _____________________________
Cardholder Name _________________________________
Expires_____/_____/_____
Signature __________________________________
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Fee(s) Received $ __________
Office use only Check # __________ Insurance Received _________________________
Approved By ______________________________________
Date Approved ______/______/_____
Post Event Inspection By ____________________________
Results: _____ Acceptable
_____ Unacceptable
Comments ________________________________________________________________________________________________
