Forms

Usage Form

EMMAUS LUTHERAN CHURCH—TOWN OF LIND

N180 County Road A, Waupaca, WI 54981

FACILITY USAGE FORM

All sections must be completed TEN DAYS prior to the Activity to process facility request.

NAME OF ORGANIZATION:______________________________________

NAME OF OFFICIAL REPRESENTATIVE:__________________________

Address: ______________________________       Phone:________________

               ______________________________      

               ______________________________       Email:________________

Date of Event and Time?__________________       Are You an Emmaus Member?______________________________

Purpose of Use__________________________       _____________________

______________________________________       _____________________

______________________________________       _____________________

IS ACTIVITY OPEN TO PUBLIC:___________

WILL A FEE OR ADMISSION BE CHARGED?   _____________________

(If your organization does not have insurance coverage the facility request may be denied)

DOES THE ORGANIZATION HAVE INSUREANCE TO COVER EITHER PERAONAL OR GENERAL LIABILITY?___

IF YES, PLEASE STATE COVERAGE:_____       _____________________

I _______________________________ being the official representative of _____________________, do hereby represent and state that I make this application on behalf of said organization and that I am authorized to do so; that I hereby acknowledge receipt of a copy of the regulations pertaining to the use of said public buildings and have read them and understand them; that I am authorized by said organization to agree and on behalf of said organization do hereby agree that said organization will abide by all the rules of Emmaus Lutheran Church TOL in regard to the uses of Emmaus Lutheran Church TOL by the public and that said organization assumes full responsibility for any and all liabilities arising out of and incident to said occupancy and that said organization does hereby agree to indemnify and hold harmless Emmaus Lutheran Church TOL from any said liability that it is further understood by man and agree to on behalf of said organization or the public invited there to by said organization. When finished with the event, the facility needs to be left in the same shape as when you got there and all garbage needs to removed.

______________________________________       _____________________

  Signature of Official Representative                          Date