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VILLAGE OF FAIR HAVEN 14523 Cayuga Street P. O. Box 614 Fair Haven, NY 13064 APPLICATION FOR USE OF VILLAGE FACILITIES Today’s Date: Date(s) Requested: Facility Requested: INFORMATION ABOUT YOUR GROUP Name of Organization or Individual: Time: Supervisor in charge: Mailing Address: Telephone: INFORMATION ABOUT YOUR INTENDED USE OF VILLAGE FACILITY Purpose of Use: Total Participants Expected: Adults: Children: Is material or equipment required from municipality? If needed, state what types and for what purpose: Residents (Number): Non-Residents Is an admission charged? If so, what will proceeds be used for? AGREEMENT The undersigned is over 21 years of age and has read this form and attached regulations and agrees to comply with them. He/she agrees to be responsible to the Village for the use and care of the facilities. He/she, on behalf of hereby covenant and agree to defend, indemnify and hold harmless the Village of Fair Haven from and against any and all liability, loss damages, claims, or actions (including costs and attorney’s fees) for bodily injury and/or property damage, to the extent permissible by law, arising out of or in connection with the actual or proposed use of the Village of Fair Haven property, facilities, and/or services by the Village of Fair Haven. Signature of Organization’s Address Supervisor or Individual Telephone Number: READ ATTACHED REQUIREMENTS AND RETURN APPLICATION TO: VILLAGE OF FAIR HAVEN P.O. BOX 614 FAIR HAVEN, NY 13064