2. APPLICATION FOR THE USE OF THE SOUTHOLD TOWN RECREATION 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) WEEKS BEFORE DATE OF EVENT
   If building is locked, the applicant listed on this form must pick up and return the key at the Southold Town Police Department. You must lock up when finished. NOTE: No food or drink is permitted in the Peconic Community Center.
8. If the applicant not available, please list name of person responsible: Name of person picking up key.
10. The Southold Town Recreation Center is available for activities to local groups that are non-profit, service, community, or civic in nature
12. Requesting Organization*
    Security deposit of $250 is required and due at the time the application is approved. Email notification and instructions will be sent.
14. Is organization civic, community, service, or non-profit*

    1. Yes
    2. No
15. I request that the $250 security deposit fee be waived.

    1. Yes
    2. No
16. Reason
18. First Name*
19. Last Name*
21. Mailing Address
23. Mailing Address
25. City
26. State
27. Zip
29. Home Phone
30. Business Phone
32. Cell Phone
33. E-mail Address*
35. Date(s)*
    MM/DD/YYYY format. Separate dates using a comma, use a (-) for a range.
36. Day(s) of the week
    Separate days using a comma.
37. Start and End Time*
    Start and End Time Start Time

    —

    Start and End Time End Time
39. Approximate number of people attending*
40. Rooms Requested*

    Check all that apply. (R = Recreation Center, C = Community Center)

    1. Mail Hall (R)
    2. Conf. Room (R)
    3. Kitchen (R)

    1. Room 1 (C)
    2. Room 2 (C)

    1. Room 3 (C)
    2. Auditorium (C)
42. Reason for use (Please be specific)*
44. Fees charged to participants (if any)
46. Funds being used for what purpose
48. Certificate of Insurance and / or other related documents
    If required, please attach your Certificate of Insurance.
50. Additional Comments
54. 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.
56. Facilities Condition*

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

    We are glad that we are able to provide your group with a meeting place. Groups must throw away all garbage and sweep and mop as needed. Our custodians have cleaning schedules exclusive of outside groups who use our facilities and we need to make sure that the building is ready for future groups and activities. Thank you for your time and cooperation regarding this matter.
60. RECREATION CENTER POLICIES, RULES, AND GUIDELINES
    Kindly contact the recreation department at 631-765-5182 if your group cancels a meeting date. The following policies, rules and guidelines apply to all groups and organizations utilizing the recreation center: 1. The applicant agent is wholly responsible and liable for any damage to the building or grounds occupied by their group or organization. Unless waived, a security deposit of $250 will be required for use of the recreation center. The security deposit will be returned within 21 days of the event or the date of the last meeting of the year provided there is no physical damage to the premises and its furnishings. If issues are not addressed within 14 days, the security deposit will be forfeited. 2. The applicant agent is responsible for the safety of occupants while the building or grounds are being used by their group or organization. 3. The building must be left clean and orderly and in its original condition. Groups are not allowed to store materials, supplies, equipment, etc. in the recreation center. 4. A Town of Southold employee will have access to the building at all times and may, in his/her discretion, revoke permission for use of the building or grounds. 5. If a Town-sponsored event conflicts with an approved date, building and grounds use may be cancelled without advance notice. 6. Groups requesting use of the recreation center must be non-profit, service, or civic in nature and based in Southold. A majority (at least 65%) of the group members must be residents of the Town of Southold. 7. The applicant agent is responsible for any advance preparation required including the set-up of tables and chairs. The building or grounds must be returned to its original condition. This includes sweeping, mopping, garbage pick-up, etc. or the security deposit will be forfeited. 8. Only Town-sponsored activities will be serviced by the custodial staff. 9. Failure to abide by the rules and policies of the building and grounds use will result in denial of permission to utilize the facility for the scheduled event as well as future use and enjoyment. 10. Smaller groups must use the conference room unless a special exception is granted. 11. Evening and weekend groups must contain a minimum of 15 people. Building use will be denied for groups with fewer members at these times. Smaller groups must use either the conference room or the Peconic Lane Community Center. (Continued on other side) 12. No alcohol may be consumed, sold, or provided on the premises at any time by any individual or group utilizing the facility. 13. NO SMOKING in any area of the building (main hall, conference room, bathrooms, kitchen, hallway, etc.) 14. Ceiling and wall decorations, paintings, and posters must be displayed under the direct supervision of the custodial staff. No use of tacks, nails, glue, etc. is permitted unless prior approval is granted. 15. Open use for informal groups to play ping-pong, billiards (pool), and cards shall be permitted only when building is not in use by other groups or organizations. 16. A certificate of insurance (naming the Town of Southold as additional insured) may be required and is the responsibility of the applicant. 17. The Town reserves the right to limit the number of dates a group uses the recreation center. 18. All activities, programs, meetings, etc. must be approved by the recreation department and the town supervisor.
62. Full Name of Applicant*
    I have read and agree to Recreation Center Policies, Rules, and Guidelines for the use of the Southold Town Recreation Facilities. By entering your name in the space provided above you agree to abide by terms specified.
66. FOR OFFICIAL USE ONLY
68. Certificate of Insurance Required? (Yes) / (No)
69. 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
71. Facility Is: (Available) / (Not-Available)
72. Recreation Department (Signature)
    ___________________________________________
74. Request Is : (Approved) / (Denied)
75. Town Supervisor (Signature)
    ___________________________________________
Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

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