Date(s) Requested:
________________________________________________________________
Meeting Time is from ____________ to __________
Organization’s Name:
_________________________________________________________________
Purpose of Meeting: _________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
___________________________________________________________________________________
Please attach a brief description of your
organization. [You may attach other printed materials.]
Please check the boxes on all that apply to your
organization:
[ ] Has previously used
the library.
[ ] Is a not-for-profit
organization.
[ ] Membership is
predominately from Seekonk.
[ ] Can provide a
certificate of insurance.
[ ] Plans to serve
refreshments.
By
signing this request, I acknowledge that I have read and fully understand the Seekonk
Public Library’s Policy and Regulations for the use of the Seekonk Library
Meeting Room. I agree to assume
personal responsibility for my organization’s compliance with these
regulations, the behavior of all those attending any meeting or program, and
the care of the meeting room and all library property within the room.
As
the individual or the accredited representative of the organization making the
reservation, I agree to indemnify and hold harmless the Seekonk Public Library,
the Town of Seekonk, its agents and representatives, from any and all suits,
action, claims or demands of any character or nature arising out of or brought
on account of any injuries or damages sustained by any person as a consequence
or result of using the meeting room, its furnishings or its equipment.
As
the individual or the accredited representative of the organization making the
reservation, I agree to pay all fees and other associated costs for use of the
meeting room as required by the Board of Library Trustees.
Person Making Request:
_________________________________________________________
(Please print your name)
_____________________________________________________________________________
(Signature of Person Making
the Request)
Date:
____________________________________
Contact Person:
__________________________________________________________
(If other than the
representative signing above.)
Representative’s Address:
_______________________________________________________
________________________________________________________
Telephone:
___________________________ Fax:
_________________________
E-mail:
______________________________________________________________