K-2 - City Hall Rental - Lions Blood Drive

City Hall Council Chambers Reservation Application $50.00 Usage Fee—Tiffin Residents $100.00 Usage Fee—Non-Tiffin Residents Usage fee is due the week of event $100.00 Refundable Deposit (Required at the time of reservation, check only) Return completed form to City Hall Type of Event: Blood Drive Sponsored by Clear Creek Lions Club Location: CITY HALL COUNCIL CHAMBERS Reservation Date: June 5 2023 Reservation Time: 12:00 - 7:00 PM Estimated number in Group: 15 Event Time: 2:00 PM - 6:00 PM Applicant Name: Clear Creek Lions Club Kevin Swanson Date: March 13 2023 Mailing Address: 1408 Green Oak Pass Tiffin Iowa 52340 Street and/or P.O. Box City State Zip Phone Number: 217-855-3730 Alt. Number: 217-433-0056 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: Kevin Swanson March 13, 2023 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: ____________________________________________ ____________________________