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PARK FACILITY RESERVATION APPLICATION

City of Florence Public Services Department

8100 Ewing Boulevard

Florence, KY 41042

859-647-5416 (Phone) 859-647-5438 (Fax)

Today's Date: ________________________ Date(s) Requested: _____________________________

Time of Rental: From ____________ am / pm___ to ____________am / pm__

PARK FACILITY REQUESTED (Check all that apply):

Florence Nature Park Kalb Gathering House:

Florence Nature Park Gazebo:

Stringtown Park Shelter:

South Fork Park Shelter:

Orleans Park Shelter:

RENTER INFORMATION

(Please Print) Name of Individual or Organization: ________________________________________________________

Adult Contact in Charge During Event: __________________________________________________________________

Address/City/Zip___________________________________________________________________________________

E-Mail:_____________________________________________________________________________________________

Telephone: (Day) ______________________ (Night) _____________________Cell phone: _________________________

Purpose of Use: __________________________________ Participants Expected: Adults: _______ Children: ______

Florence Park Facility Kalb Gathering House Facility Deposit (

Rental Fee:

$_____________

if applicable): $___________

(if applicable)

AGREEMENT

The undersigned is over 21 years of age and has read this form and attached regulations and agrees to comply with them.

He/she agrees to be responsible to the City of Florence for the use and care of the facilities. The undersigned does hereby

further covenant and agree to defend, indemnify and hold harmless the City of Florence, its’ elected officials, officers, and

employees from and against any and all liability, loss, damages, claims, or actions (including costs and attorneys fees) for

bodily injury and/or property damage, to the extent permissible by law, arising out of or in connection with the actual or

proposed use of the City of Florence’s property, facilities and/or services. I have read and understand the rules and

regulations provided for the park facility reserved and agree to abide by them.

Applicant Signature: ________________________________________________ Date: _______________________

FOR OFFICIAL USE ONLY

Authorized City Representative Signature: ________________________________ Date: ________________

Payment: Amt. _____________

Cash or Check#_____________

Money Order # __________________

Credit Card: MC _____ VISA _____ AE _____ DISC _____ Card # _________________________________________________

Expiration Date _________ CVV Code _______ Card Signature ___________________________________________________

Park Facility Reservation Application Form - City Of Florence Public Services Department