Request for Farnham Farm Facilities/Property

Conditions 1. Users must clean after facility or property use. The user must repair any damage to thebuildings, furniture, equipment or property, or replace damaged items.2. Users must not violate, nor permit the violation of any local, state or federal law inconnection with their activities.3. Serving alcoholic beverages is prohibited unless specifically approved and a liabilitypolicy certificate is provided.4. At the discretion of Prudence Conservancy, Inc, a Liability Release Form shallaccompany requests.5. No open fires are permitted.

Date of Request (eg. 01//5/05):

Requestor

Name:

Address (street, town, state, zip):

Phone (area code & number):

Email:

Check the facility you would like to use.

Hope Brown Center: Land:

Will you need an audio video/system?

Yes: No:

When would you like to use the facility?

Date (eg. 01//5/05): Time (eg., 10:35 AM):

What is the frequency of this activity?

One time: Weekly: Monthly:

If this activity is weekly or monthly, please specify day and time.

Day: Time:

What is the name of the group that will use the facility?:

Describe the proposed activity:

Who will be in charge of cleaning and/or picking up after the activity?

Name: Phone Number: