BALTIMORE COUNTY DEPARTMENT OF RECREATION AND PARKS
FACILITIES USE APPLICATION

Please fill out a separate request for each site.  Include all needs including registration, coach’s meetings, awards ceremonies, recitals, etc.

											PERMIT NUMBER   

ARE YOU A RECREATION COUNCIL PROGRAM?     YES      NO

PROGRAM (OR ORGANIZATION) NAME:  				

CHAIRPERSON (OR APPLICANT) NAME:      

PHONE          	                                                  EMAIL ADDRESS:   
	
ADDRESS       					                                        CITY:    		                ZIP:

FACILITY        

DESCRIPTION OF ACTIVITY                                                                                                              ESTIMATED ATTENDANCE                                                                                                                                                  

SERVICES REQUESTED:          AUDIO          LIGHTING       TABLES REQUESTED                      CHAIRS REQUESTED                        
       
Include time for set-up and clean-up, if necessary	
start /end
dates	day of week	open
time	close
time	# of wks	hrs daily	total hrs	gym	café	aud	class-room	multi-purpose rm	grounds
(specify)	other
(specify)	
	MON
													
	TUE
													
	WED
													
	THU
													
	FRI
													
	SAT
													
	SUN
													
Having read and agreed to the regulations governing the use of facilities described on the reverse side, I, the undersigned being a duly authorized officer of the above organization, do hereby request the use of the facility as described above.
SIGNATURE OF CHAIRPERSON/APPLICANT            	Date	

Please indicate representative from organization who will be present and responsible during activity:

Cell  

Home  

NAME                                                                                        PHONE

FOR OFFICE USE ONLY                                                                                APPLICATION:           APPROVED    NOT APPROVED   

Rental Information:   Total Hours:                         Hourly Rate:                               Total Rental Fee:                   
 
Staff Information:     Additional Attendant Required       YES        NO   
                                  Total Hours:                          Hourly Rate:       $20.00             Total Staffing Fee:                 

Payment Information:  Total Due:                          Date Rec’d                                  Invoice No.              

Comments: 

SIGNATURE R&P STAFF MEMBER                                                                                                        DATE                             

Copies:      White – Department of Recreation & Parks      Yellow- Local File        Pink-User       Gold-Attendant/Custodian