Field Requested Form (CAMPS)

Requestor _______________________________

Field _______________________________

Dates and times the field will be needed

Reason for request

Non-Profit Organization Yes No

Insurance Binder Yes No

Participation Consent Forms Yes No

Field Use Fee (A flat fee of $150 is charged per camp) Yes No

Board of Health Approval ________________________

Signature of Board of Health Representative

(BOH approval is required if an activity meets at least three times over a two week period.)

Please add any further information in the space provided:

Approved by the following members of the Playground and Recreation Commission:

Sign:_____________________ Date__________

Sign:_____________________ Date__________

Sign:_____________________ Date__________

Sign:_____________________ Date__________

If the request is denied, provide the reason below.