Village of Grand
Rapids
PO Box 309
Grand Rapids, OH 43522
(419) 832-5305
(419) 832-0561 - fax
Name of Group: _______________________________________________________________
Address: ________________________________________ Phone: ___________________
City: _______________________________________ St.: ________ Zip: ______________
Contact Person: __________________________________________________________________
Address: ________________________________________ Phone: ___________________
City: _______________________________________ St.: ________ Zip: ______________
Date of Reservation: _________________________________
Hours: __________ am/pm (circle) to __________ am/pm (circle)
Location: __________________________________________
The party using the public property shall return the area to the condition before the event, including removal of all trash from the area. If you bring it to the area, remove it.
Name of Insurance Company: ________________________________________________
(Please attach a copy)
INDEMNIFICATION AGREEMENT
The ___________________________________________ agree to defend, idemnify and hold harmless the Village of Grand Rapids from any claim, demand, suit, loss, cost of expense, or any damage which may be asserted, claimed or recovered against or from the Village of Grand Rapids by reason of any damage to property, personal injury or bodily injury, including death, sustained by any person whomsoever and which damage, injury, or death, arises out of or is incident to or in any way connected with the performance of this contract, and regardless of which claim, demand, damage, loss, cost of expense is caused in whole or in part by the negligence of the Village of Grand Rapids, ___________________________ or by third parties, or by the agents, servants, employees or factors of any of them.
Signature: ____________________________________________ Date: _________________
Witness: ____________________________________________ Date: _________________