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Southold Park Facilities Use Request Form

  1. APPLICATION FOR THE USE OF THE SOUTHOLD TOWN PARK FACILITIES

  2. Janet Douglass Recreation Supervisor, Southold Recreation Department

    970 Peconic Lane, P.O. Box 267, Peconic NY 11958, janetd@southoldtownny.gov, 631.765.5182

  3. APPLICATIONS DUE AT LEAST TWO (2) MONTHS BEFORE DATE OF EVENT

    Payment is due when the application is approved.

  4. Facilities Requested*

    Check all that apply

  5. MM/DD/YYYY format. Separate dates using a comma, use a (-) for a range.

  6. Separate days using a comma.

  7. 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.

  8. Is admission being charged?*

  9. If required, please attach your Certificate of Insurance.

  10. 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.

  11. Parks and Facilities Condition*

    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.

  12. FOR OFFICIAL USE ONLY

  13. Certificate of Insurance Required? (Yes) / (No)

  14. 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

  15. Facility Is: (Available) / (Not-Available)

  16. Recreation Department (Signature)

    ___________________________________________

  17. Request Is : (Approved) / (Denied)

  18. Town Supervisor (Signature)

    ___________________________________________

  19. 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.

  20. Leave This Blank:

  21. This field is not part of the form submission.