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NGSCA Portable Stage Use Application
This form is to request the use of the New Gum Springs Civic Association Portable Stage within Fairfax County. The stage may not be rented/used outside of Fairfax County.
Name
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First
Last
Cell Phone
*
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###
-
####
Email
*
Alternate Phone
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-
###
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####
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Organization Type
*
Please select
Fairfax County Government
Other Governmental
County-based Nonprofit
Other
Name of Fairfax County Organization/Agency
*
Name of Organization if not a Fairfax County Organization/Agency
*
Title/Subject/Purpose of Activity
Fee
*
$
Dollars
Fairfax County Government -- No Fee
Other Governmental includes Fairfax County Public Schools, Little League, Scouts and other Civic Associations -- $25
County-based Nonprofit Organization, includes other non-profit organizations based in Fairfax County to include churches - $25
Others includes all businesses, organizations and groups whose mailing address or functions are based in Fairfax County which do not qualify as an organizationunder governmental or County-based non-profit -- $100
First Choice Date
*
Time (From-To)
*
Second Choice Date
*
Time (From-To)
Location of where stage will be used to include name of facility
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Permission granted for use of the New Gum Springs Civic Association (Civic Association) stage by any organization or individual may be revoked, cancelled, postponed, or rescheduled. The Applicant accepts liability and any damage identified by the Civic Association or County staff in connection with the use of the stage. The Applicant hereby agree to indemnify and hold harmless the Civic Association, its officers, agents, Fairfax County staff and volunteers, from any and all claims for bodily injury, personal injury and/or property damage in connection with the use of the stage. The Applicant is responsible for providing the required assistance under the Americans with Disabilities Act. In the event of damage, the Applicant will have repair(s) completed within 30-days depending on the extent of the damage. Otherwise, the Applicant will be required to replace the stage.
By stating "YES" in the box below, the Applicant acknowledges receipt of a copy of, read and agrees to comply with the requirements for use of the Civic Association’s stage and any special conditions noted below. The Applicant also understands that he/she may have to reapply if any changes are made to this application.
*
Stage users must provide two people to assist the County staff with assembly and disassembly of the stage. If no help is provided by the user, there may be delays or denied use of the stage.
Special Conditions of Approval
Applicant Signature
*
Your typed signature will be accepted as your authorized electronic signature
Date
*
MM
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DD
/
YYYY
Signature of NCS Staff
Your typed signature will be accepted as your authorized electronic signature
Date
MM
/
DD
/
YYYY
Signature of President, NGSCA
Your typed signature will be accepted as your authorized electronic signature
Date
MM
/
DD
/
YYYY
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