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FACILITY USE REQUEST

Richardson Community Center 255 NE Coach Anders St, Lake City, Florida 32055 Telephone
(386) 754-7095, Fax (386) 754-7097. Columbia County upon the terms and conditions agrees to rent certain or all portions of the
Richardson Community Center in Columbia County, Florida, to the group herein described as Applicant Insurance agreement is
enclosed.

Group/Agency: ______________________________________

Date: ___________________________________

Nonprofit: 501(3) c __________________________________


Phone: ________________________________
EVENT STARTING TIME:

Email: __________________________________
EVENT ENDING TIME:

FACILITY SPACE REQUESTED


Fee per Day:
Gymnasium
Cafeteria/Kitchen
Concession Stand
Softball Field
Basketball (outside courts) tournament only
Ferguson Building
Conference Room
Entire Complex
Total

$300.00
$200.00
$75.00
$50.00
$50.00
Do Not Rent
Do Not Rent
$500.00

ADDITIONAL ITEMS REQUESTED (please specify equipment needed):


Chairs # _____________
Gym Equipment: _______________________________________
6 ft. Tables # __________
Kitchen Equipment: ____________________________________
8 ft. Tables #__________
Round Tables#_________
Other: ____________________________________________________________________________________
Applicant agrees to all Terms and Conditions set forth in the policy for use of Facility and Equipment Form Attached
Signature of Applicant: ______________________________________________

Date _____________

Applicant Drivers License# or Proof of ID: ___________________________________________


Richardson Community Center
Authorized Representative: ___________________________________________
Approved_________

Date_____________

Denied__________

Make Check Payable to: Richardson Community Center/Annie Mattox (North) Inc.
(RCC/AMN Inc)
Payment Date: _________________

Amount: ______________

Payment Received: Yes ________No__________ Check/Money Order No: _______________________________________

POLICY FOR USE OF FACILITY & EQUIPMENT


If Group/Agency is using the Facility as a community center for family functions (reunion/gatherings) or
other nonprofit community events which will be covered under Columbia Countys liability insurance, no
additional insurance shall be required. Other Groups/Agency users shall supply a certificate of insurance
reflecting minimum coverage of $1,000,000 bodily injury and $100,000 property damage. Columbia County shall
be named as additional insured which shall be noted on the certificate. The certificate shall indicate the insurance
must be provided to the County no later than three (3) business days prior to the event or as otherwise required
by the County.
All Group/Agencies using the Facility, including its contractor, agents, and employees, hereby agree to
indemnify and hold harmless Columbia county and its officers, agents and staff from and against any and all
liability, claims, damages, demands, expenses, fees, fine, penalties, suits, proceedings, actions, copyright
violations growing out of and in any way connected with the Group/Agencys use of the Facility in accordance
with this agreement.

1. The Richardson Community Center/Annie Mattox (North) Advisory Council representative will notify you to
schedule an appointment once the request has been approved or denied. Until then, the request is not
approved.
2. Conflicts: Any reservation conflicts will be resolved by Richardson Community Center office.
3. Changes: If there are any changes to your original request after it has been approved, you must contact the
office.
4. Priority: Richardson Community Center functions have absolute priority when considering availability.
Calendar reservations may be made 12 months to 1 week in advance of the event date with approval.
5. All rentals may last no longer than 12:00 am.
6. Strictly Prohibited: The use of alcohol, illegal substances or profanity (including loud music) will be prohibited
on any part of the property. Restrictions: Smoking will only be allowed in designated areas
7. In the event that this request is approved, you will be responsible for, but not limited to, the following:
Cleanliness of the facility space used
Cleanliness of any rest rooms used
All trash placed in dumpster
All lights are to be turned off
All doors must be locked upon exiting the building
8. Applicant must be at least 18 years old to rent the facilities.
9. If rental agreement is signed less than 30 days prior to the event a 50% non refundable deposit is due upon
approval and the balance is due at least one (7days) week prior to the event
10. For events needing security (at the discretion of the RCC/AMN Inc.), (2) Columbia County Sheriffs
Department officers shall be present at a rate of $35.00/hr. This rate is addition to any rental fees paid.
I have read the above policy, understand the approval process and will be responsible for what is required to
use the facility in the event that this request is approved.
Signature:
For questions or further needs, please contact:
Mario Coppock, Facility Director or
Nicole Smith, Facility Secretary
Phone (386) 754-7095 Fax (386) 754-7097