Dingman Township
Recreation Commission
Field Use Application
Applicant Contact Person
__________________________________ _________________________________
Address Address
__________________________________ _________________________________
Phone Phone
__________________________________ _________________________________
FIELD DATES REQUESTED TIMES
__________________ ____________to_____________ ______ to ______
__________________ ____________to_____________ ______ to ______
__________________ ____________to_____________ ______ to ______
ACTIVITY
# OF TWP RESIDENTS
# OF TEAMS
________________________________
___________________
______________
It is understood that the
applicant shall:
A. Have at all times, while
the permit is in effect, a general liability insurance policy with minimum
limits of liability in the amount of $1,000,000 combined single limit for each
occurrence and $1,000,000 combined single limit for general occurrence.
B. Provide a certificate of
insurance with Dingman Township named as an additional insured.
C. Save, defend, keep
harmless, and indemnify the Township and its appointed and elected officials,
officers, servants, agents, and employees from and against any and all attorney
fees, charges, liability or exposure, however caused, resulting from or arising
out of or in any way connected with the applicant’s activities.
D. Upon request, provide a
complete roster, with names and addresses, of all members of the applicant’s
organization, and be kept current throughout the year.
E. Comply with all township
rules, regulations, resolutions, and ordinances governing the use of the fields.
A copy is attached.
Attest:
_________________________
Signature: ____________________________
_______________________________
_____________________________________
Name and Title (Printed)
Name and Title (Printed)
Date:_________________