2. APPLICATION FOR THE USE OF THE SOUTHOLD TOWN PARK FACILITIES
4. Janet Douglass Recreation Supervisor, Southold Recreation Department
   970 Peconic Lane, P.O. Box 267, Peconic NY 11958, janetd@southoldtownny.gov, 631.765.5182
6. APPLICATIONS DUE AT LEAST TWO (2) MONTHS BEFORE DATE OF EVENT
   Payment is due when the application is approved.
8. Today's Date*
   Today's Date
10. Requesting Organization*
12. Applicant First Name*
13. Applicant Last Name*
15. Mailing Address*
17. City*
18. State*
19. Zip*
21. Home Phone*
22. Business Phone
23. Cell Phone
25. E-mail Address*
27. Facilities Requested*

    Check all that apply

    1. Cochran Park
    2. Tasker Park
    3. Strawberry Fields

    1. Peconic Community Center Fields
    2. Downs Farms (Fort Corchaug)

    1. Laurel Lake Baseball fields
    2. East Marion Schoolhouse Park
29. Date(s) Requested*
    MM/DD/YYYY format. Separate dates using a comma, use a (-) for a range.
30. Day(s) of the week
    Separate days using a comma.
32. Requested Time: Starting - Ending*
    Requested Time: Starting - Ending Start Time

    —

    Requested Time: Starting - Ending End Time
33. Requested Time for Lights: Starting - Ending
    Requested Time for Lights: Starting - Ending Start Time

    —

    Requested Time for Lights: Starting - Ending End Time
    Requested time for lights to be on (if applicable). Field/court lighting will not be available from January 1 – March 1. NOTE: LIGHTS MUST BE TURNED OFF BY 10:00 P.M.
35. Individual responsible for picking up the key for lights
37. Reason for use (Please be specific and elaborate)*
39. Is admission being charged?*

    1. Yes
    2. No
40. If yes, how much is being charged?
42. Provide a detailed explanation of how the proceeds are to be used.
44. Certificate of Insurance
    If required, please attach your Certificate of Insurance.
46. Additional Comments
    Additional comments
50. HOLD HARMLESS AGREEMENT
    The applicant/group/organization agrees to indemnify and hold harmless the Town of Southold, its officials, employees, and/or agents from all claims, lawsuits, hospital and/or doctor bills, actions, proceedings, and liabilities for the loss or damage to property, or any injury, the death of a person, including any expenses incurred by the Town of Southold defending any claims, lawsuits, or action that may arise as a result of the conduct, actions, including the negligence of the applicant/group/organization to the fullest extent permitted by applicable law.
52. Parks and Facilities Condition*

    1. If checked you agree to the terms specified in this paragraph.

    I have read the "SOUTHOLD TOWN FACILITY RULES AND REGULATIONS" (See below) and agree to abide by them. We are glad that we are able to provide your group/organization/league with a facility. Your group is required to make certain that the field is free of debris when you leave for the day. Our staff has maintenance schedules exclusive of outside groups who use our facilities and we need to make sure that the field is ready for future groups and activities. Thank you for your time and cooperation regarding this matter.
56. FOR OFFICIAL USE ONLY
58. Certificate of Insurance Required? (Yes) / (No)
59. Special Events App. Required? (Yes) / (No)
    If yes, please download and fill out a special events application. http://southoldtownny.gov/392/Zoning-Board-of-Appeals-Department
61. Facility Is: (Available) / (Not-Available)
62. Recreation Department (Signature)
    ___________________________________________
64. Request Is : (Approved) / (Denied)
65. Town Supervisor (Signature)
    ___________________________________________
69. SOUTHOLD TOWN FACILITY RULES AND REGULATIONS
    Click here to view the rules and regulations

    FOR FURTHER INFORMATION, PLEASE CONTACT THE SOUTHOLD RECREATION DEPARTMENT AT 631.765.5182.
71. Full Name of Applicant*
    I have read and agree to Recreation Center Policies, Rules, and Guidelines for the use of the Southold Town Parks and Facilities. By entering your name in the space provided above you agree to abide by terms specified.
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit Submit and Print

* indicates a required field