Ridge/Jenkinsville Park Athletic Complex

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Ridge/Jenkinsville Facility Use Application

Queensbury Parks & Rec

Queensbury Department of Parks & Recreation
742 Bay Road, Queensbury, NY 12804
(518) 761-8216 ~ fax (518) 798-3194


*Required

CONTACT INFORMATION

insurance certificate required

*Name of person responsible for event/field use:
*Application on behalf of:

*Name of Organization/Group:
*Address:

*Town/Zip:
*Phone:

*Email:
*Insurance Carrier/Policy #:

FIELD USE INFORMATION

attach additional information as necessary

*Activity fields to be used for:
Day(s) of week needed:

Number of fields needed::
Est. Attendance:

Start Date:
End Date:

Start Time:
End Time:

Will Admission be charged:
Will Concession Area be used (separate fee and application necessary)?:

Additional Comments or requests pertaining to your application::
*Signature:

TOWN OF QUEENSBURY HOLD HARMLESS AGREEMENT

The Licensee agrees to indemnify and save harmless the Town of Queensbury and its agents and employees (hereinafter referred to as “owner”), from and against all claims, damages, losses and expenses (including, but not limited to attorney’s fees), arising out of or resulting from performance of the work sustained by any person or persons, provided that any such claim, damage, loss or expense is attributable to bodily injury to or destruction of property caused by the negligent act or omission of the licensee, its employees, agents or subcontractors.

*Signature:
*Date:

*Organization represented:
*Address:

*City:
*State/Zip:

I acknowledge that I have received a copy of the emergency action plan for the Ridge/Jenkinsville Athletic Facility, and ensure that it will be followed in the case of an emergency.

*Signature:
*Date:

*Passcode:
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