LOWER PROVIDENCE TOWNSHIP DEPARTMENT OF PARKS & RECREATION

100 Parklane Drive Eagleville, PA 19403

Phone: (610) 635-3543 Fax: (610) 539-6347

www.LPTREC.com

FACILITIES RENTAL REQUEST FORM

This form represents a REQUEST to Lower Providence Township Parks & Recreation Department from the stated organization through its authorized representative.

APPROVAL BY THE PARKS AND RECREATION DEPARTMENT WILL NOT BE GIVEN UNTIL PAYMENT (security deposit & rental fee, if applicable) AND PROOF OF INSURANCE COVERAGE HAS BEEN RECEIVED (if applicable). Checks must be made payable to "Lower Providence Township".

Applicant Name:

Organization:

Address:	City/State: Zip:

Home Phone: Work Phone:

Cell Phone: Email:

Please check the facility that is requested:

☐ Eagleville Park - Bocce Court (R)$10 per 2hrs (NR)$15 per 2 hrs ☐ Eagleville Park - Gaugler Field ☐ Gabriel Field

☐ Eagleville Park – Pavilion $60.00 full day/(NR) $120.00 ☐ Eskie Park Field 1 ☐ OTHER_____________

☐ Eskie Park Pavilion $60.00 full day/ (NR) $120.00	☐ Eskie Park Field 2

☐ Level Rd. School House (Max. 50 people) (R) $125 4-6 hrs (NR) $175 4-6 hrs

Rental Date:	Time: -	Estimated Attendance #:

For rentals of more than one (1) day …PLEASE attach a list of ALL Dates / Days / Times requested.

By signing below, I (we) duly elected officer(s) or duly appointed committee of the above said organization, certify that our organization agrees:

To assume all risks in connection with the use of the facilities requested above and to hereby release, absolve, indemnify and hold harmless the Township of Lower Providence and its employees in connection with the use of these facilities.

That the responsibility for carrying appropriate medical plans, including hospitalization, lies with our organization and/or participants, since the Township of Lower Providence does not carry such insurance.

To adhere to the Rules and Regulations for Parks and Recreation facilities, a copy of which as been received.

To notify the Township of Lower Providence in writing within 24 hours of any hazardous conditions which exists.

That a Security Deposit is required and will be returned upon completion of facility inspection pending that no damages were observed.

Please provide TWO separate checks: one for security deposit and one for rental fee. Provided all conditions are met, security deposit will be returned.

Security Deposit Amount:	Check - #:	Cash -

$100.00 deposit for pavilions

Rental Fee(s) Amount:	Check - #: Cash -

Credit Card - Circle: Visa or MasterCard

Card #:

Expiration Date: CVV2 #:

Applicant Signature:	Date:

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For Department Use Only

I hereby certify that an inspection was conducted on the premises. The condition of the premises was as follows:

NO DAMAGES WERE OBSERVED (initial)_________

THE FOLLOWING DAMAGES WERE OBSERVED:____________________________________________________________________________________________________________________

Damages Observed By	Date

Amount of Fee(s) Returned: ____________________ Method of Refund: ____________________ Date: ____________________ Initials: ____________________

Revised 4/25/2019