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Community Room Application
"
*
" indicates required fields
Meeting or Event Purpose (be specific)
*
Date of Meeting
*
Month
Day
Year
Beginning Time (Including set-up)
*
Hours
:
Minutes
AM
PM
AM/PM
Ending Time (Including tear-down)
*
Hours
:
Minutes
AM
PM
AM/PM
Number in Group (50 per room, 150 maximum)
*
No. of Rooms Requested (1, 2 or 3)
*
1
2
3
Kitchen Access ($25.00 suggested donation)
*
No
Yes
Number of 6'x30" Rectangle Tables Needed (seats 4-6 adults)
*
Number of Chairs Needed
*
Applicant Making Request
Must live or own property in Jefferson, Middlebury, or York Township
Name
*
First
Last
Address
*
Street address, City, State, Zip Code
Phone
*
Email
*
If not applicable, type NA
Policy and Conditions
*
The applicant, on behalf of the above organization, acknowledges that he or she has read and agrees to comply with the rules governing public use of the community room located at the Middlebury Public Library. The applicant accepts full responsibility for any damage to the Library’s facilities or equipment during such use. The applicant further agrees to hold harmless, release and indemnify the Middlebury Public Library and the Town of Middlebury from any and all claims, losses, damages, or lawsuits for damages, arising in any way whatsoever from, allegedly arising from or related to the use of the Library’s facility hereunder by the organization.
I agree to the Policy and Conditions
Date
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