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REQUEST TO USE THE BRUNNER FARMHOUSE - 2012 Date: Name of Organization: Requested purpose for using the House: Is the requesting organization a Broomfield based Non-Profit? Yes No Size of group expected at the house (maximum occupancy 33) Requested Use Date: and time: Is this a occurrence? If not, how often? Any special requests or information you wish the Committee to consider? Responsible Person Information: Primary Contact Name: Home Phone: Cell Phone: Email: Home Address: Secondary Contact Name: Home Phone: Cell Phone: Email: Home Address: The mission of the Brunner Farmhouse and Gardens is to provide a community gathering place for the citizens of Broomfield. In order to continue to offer this amazing resource and connection to our past, we ask that all organizations utilizing the house, give back to the property in some way. Date obligation will be fulfilled: Below are some suggestions only. You may come up with your own ideas, suitable to needs you may discover as you use the facility or specific to your interests. Please check the item(s) your group will commit to. You may also talk with the Brunner House Committee to discuss ideas. Call [PHONE REDACTED] for current Committee contact information. Purchase of folding chair(s) $55 each Cash Donation(s) amount: Trash Bags for kitchen (minimum 36” tall) Paper Towels Swiffer Wet Cleaning Pads Other (be specific) Maintenance of outside growing bed (instructions below) Participate in Spring or Fall Cleaning Day (dates to be determined) (The commitment for the maintenance of outside growing beds will be for a full growing year. The Brunner House Committee will provide a maintenance manual and direction on which bed is available for sponsorship.) Signature: Date: Return form to: BCAH, P.O. Box 681, Broomfield, CO 80038-0681, [EMAIL REDACTED], or fax: [PHONE REDACTED]. All requests must be reviewed and approved by the Brunner Farmhouse Citizen Advisory Committee. Administrative use only: Approved Organization Notified Date Give Back Fulfilled Date Denied Reason: Door Code Provided Date Reoccurrence Tagged