First & Last Name: ___

Organization (if applicable): _____

City: _____ Zip: _____

Street Address: ___

Email: _____

Phone: ___

Park/Facility Name: ___

Time In: _____ Time Out: _____

Date of Function: ___

Please Describe Function: ___

Number of Participants: ___

Percent Park District Residents: ___

Will you charge a fee? ☐ Yes ☐ No Will you hire a caterer? ☐ Yes ☐ No

Will alcoholic beverages be served? ☐ Yes ☐ No Will alcoholic beverages be sold? ☐ Yes ☐ No Please read page 2 for information on certificates of insurance and page 3 for our alcohol policy.

Who will you secure insurance through? ☐ Personal ☐ Winnetka Park District ☐ Event Helper ☐ N/A Will you be setting up any temporary structures (e.g., inflatables, bounce houses, tents, etc.? ☐ Yes ☐ No Will you be hiring any entertainment? If yes, provide more information below. ☐ Yes ☐ No Please provide any additional information regarding your event:___

Total Enclosed: $___ Type: ☐ Cash ☐ Check ☐ Credit Card ___ Exp Date ___

Cardholder's Name: ___ Authorized Signature: ___

Acknowledgment I have read, understand, and agree to abide by the Winnetka Park District facility rental procedures and regulations. I have read and fully understand the warning of risk, assumption of risk and waiver and release of all claims.

Name (please print): ___ Signature: ___ Date: ___

** REMINDER: Renter must pick up facility/park key one business day prior to rental at the Administrative Office.

OFFICE USE ONLY: Received By: _____ Date: _____

Rental Fee: $_____ Approved By: _____ Date: _____

Copy to: ___ Renter ___ Parks ___ Police

Security Deposit $ ___

COI Received: ___ Notes: ___

Iam very