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Dean Hackett Park Meduim Ramada Fee Exemption Request

Please correct the field(s) marked in red below:

1
Name of Organization:
2
Name of Applicant/Organization Contact:
 *
3
Applicant/Organization Address:
 *
4
Applicant/Organization Phone Number:
 *
5
Applicant/Organization Email:
6
Event Location:
 *
7
Description/Purpose of Use:
 *
8
Fundraising Event:
 *
Fundraising Event:
9
Reason for Exemption:
 *
Reason for Exemption:
10
Date(s) of Events:
 *
Date(s) of Events:
11
Time of Event:
 *
12
Estimated Number of Participants:
 *
13
Additional Requests: