K-2 - Special Events Application - Blood Drive - Tiffin Lions

City Hall Council Chambers Reservation Application Type of Event: Blood Drive Location: CITY HALL COUNCIL CHAMBERS Reservation Date: 11/30/2023 Reservation Time: 1:00 pm - 6:30 pm Estimated number in Group: 15 Event Time: 2:00 pm - 6:00 pm Applicant Name: Pat Higby for Clear Creek Lions Date: 9/25/2023 Mailing Address: 718 Blue Jay Ct., Tiffin, IA 52340 Street and/or P.O. Box City State Zip Phone Number: 319-266-4934 Alt. Number: none Email: [email protected] WAIVER AND RELEASE: I agree to hold the City of Tiffin harmless from any and all claims for injury or damage to persons or property suffered in connection with the permittee’s activities unless such injury or damage is caused by the gross negligence of the City of Tiffin. As group representative, I hereby agree to take responsibility to inform and assure that all group members follow the guidelines listed below. If the key card is not returned I understand that $25 will be charged to the deposit and any damages caused could result in a loss of deposit. Signature of Group Representative: Patricia Higby 9/25/2023 Signature Date Reservation Guidelines: Leave the area clean and in order including tables and chairs back in place. Please bag up garbage and take with you. If necessary, bring additional garbage bags for your group. Key card must be returned before your deposit will be returned. Please note that pets are NOT ALLOWED inside City Hall. For Office Use: _________ Reservation Approved ________ Fee Received __________ Deposit Received __________ Calendar- Appointment Created __________ Door Programed __________ Date Key Card Returned _________ Full Deposit Returned __________ Partial Deposit Returned ________________________________ City Official Signature: ____________________________________________ Signature Date: ______________________