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Permit for Public Event Application

2. 

4. First AND Last Name*

6. Organization Name (If Applicable)

   If Tax Exempt, form and payment must match Tax Exemption ID

8. Address*

10. City, State, Zip*

12. Cell Phone Number*

    Area Code Required with - between numbers

13. Daytime Phone Number

    If different from Cell Phone

14. Email*

16. Location to Reserve*
    -- Select One --Dutton Island CampsiteDutton Island PavilionBull ParkRussell Park PavilionHowell ParkDonner Park PavilionJordan Park PavilionJohansen ParkBeach FireOther - List below

    Park permits - 4 hour intervals - PARKS CLOSE AT DUSK (all outside events must be cleaned up by 10 pm)

18. If Other Indicate Here

20. Name/Purpose of Event*

22. Description of event/activities*

24. How many people do you expect to attend? (Approximate)*

    More than 50 requires approval process of 10-20 business days.

    1. 1-15
    2. 1-25
    3. 1-35
    4. 1-45
    5. 50-75
    6. 75-100
    7. 100-300
    8. 300-500
    9. Other
26. If Other, give number

28. Date & Time Begin & End*
    Date & Time Begin & End Start Date

    Date & Time Begin & End Start Time

    —

    Date & Time Begin & End End Date

    Date & Time Begin & End End Time

    Include set up & clean up times

29. Beach Wheel Chair Reservation

    Click here to reserve Beach Wheelchair

    1. 1-2 days
    2. 1-4 days
    3. 1-7 days
31. Please answer the following:
    -- Select One --Additional equipment and/or vendors are being used for event ie: tent, chairs, bounce house, etc?Music is planned for event (Loud music and/or obscene language is prohibitedSigns, banners or decorations are being used (must be removed at end of event)Special requsts for city equipment or services?

    Please attach a site/route map if applicable for Special Event Request

33. Upload site/route map

35. Public Facility and Public Areas Disclaimer*

    1. I agree to the following Disclaimer

    All public facility and public areas should be left in good and clean condition without damage. ALL CITY POLICIES AND ORDINANCES ARE TO BE FOLLOWED. If weather is inclement, events may be rescheduled up to 30 days after submitted date of event upon notification to the Recreation Office. NO REFUNDS will be issued! For fires - charcoal, wood and any remnants of the fire must be removed from the beach, the area picked up and trash deposited in trash barrels or removed. Applicant agrees not to sell, publicize or discuss any products or services offered by self, or any organization, or to engage in fundraising activities on public property of the City of Atlantic Beach including park and beaches. Use of alcoholic beverages is not permitted in the City parks or on the beach.

37. Applicant Signature
    The APPLICANT shall indemnify, defend and hold harmless the City of Atlantic Beach, its officers, employees and agents from any and all losses, costs, expenses, claims, liabilities, actions, or damages, including bodily injury and personal injury liability for injuries to any person or persons or damage to property arising at any time during and/or arising out of, or in any way connected with APPLICANT'S use of CITY/PUBLIC property, unless solely caused by the gross negligence of willful misconduct of the City, its officers, employees or agents. By signing this application, the APPLICANT has read and agrees to accept all responsibility outlined and implied to comply with the Ordinances and Codes of the City of Atlantic Beach, the Special Event Guidelines and Policies, and all requirements stipulated for approval of this application.

    The APPLICANT shall indemnify, defend and hold harmless the City of Atlantic Beach, its officers, employees and agents from any and all losses, costs, expenses, claims, liabilities, actions, or damages, including bodily injury and personal injury liability for injuries to any person or persons or damage to property arising at any time during and/or arising out of, or in any way connected with APPLICANT'S use of CITY/PUBLIC property, unless solely caused by the gross negligence of willful misconduct of the City, its officers, employees or agents. By signing this application, the APPLICANT has read and agrees to accept all responsibility outlined and implied to comply with the Ordinances and Codes of the City of Atlantic Beach, the Special Event Guidelines and Policies, and all requirements stipulated for approval of this application.

38. Print Name*

    Applicant must be 21 years of age, (proof of Driver's License Required) This serves as an electronic signature and acknowledgement of above Disclaimers

40. Upload Driver's License Here*

41. Upload Florida Tax Exempt Certificate

    If Applicable; required for payment without tax

43. Date Signed*
    Date Signed

45. FEES

    1. $26.75 (includes tax) - Fire on Beach no larger tan 2'x2'x1' (max 20 people) Nov-Feb
    2. $25/night per site + 7 % tax- Camping at Dutton Island:primitive campsites
    3. $125/night + 7 % tax - Entire island Dutton Island campsites
    4. $26.75 (includes tax) - Wedding or event on beach or in parks
    5. $26.75 (includes tax) - Use of pavilion, parks, courts, playing fields
    6. $26.75 (includes tax) - Special event in City of Atlantic Beach (business, photo shoot, neighborhood party, festival, church, etc)
    7. Florida Tax Exemption (Must be uploaded and sent with application)

47. Total Amount Due $____________
    For Office Use Only: Paid $ ___________ Receipt # _____________ FOP: Ck # ______ Cash ______ CC _____

    For Office Use Only: Paid $ ___________ Receipt # _____________ FOP: Ck # ______ Cash ______ CC _____

49. Office Use Only:
    ID verified ________ Approved ________ Denied ________

    ID verified ________ Approved ________ Denied ________

Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit Submit and Print

* indicates a required field