Form Center

2. Downtown Activity Center Room Rental Form
4. Name
5. Date of Request
   Date of Request
7. Address
9. State
10. Zip Code
11. City
13. Email
14. Home Phone
16. Cell Phone
17. Driver's License Number
19. Room Name
20. Name of Organization
24. Is your meeting open to the public or private?
25. Will this meeting be free to attendees?:
27. Is your organization for profit or non-profit?
28. Will products be sold or marketed to attendees?
30. Will food or drinks be served?
31. Number of Attendees?
33. Agreement
    Do you agree to abide by all DACpolicies and, if the facility is not left in the condition in which it was found,agree to pay for damages?
35. Date Request
    Date Request
36. Event Time Span
    Event Time Span Start Time

    —

    Event Time Span End Time
38. Please describe your event.
42. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I Agree
44. Waiver
    I assume all risks and hazards directly related to and incidental to rental of the Downtown Activity Center. I hereby waive, release,absolve, indemnify and agree to hold harmless the City of Bentonville, the sponsors, supervisors and participants for any claim arising out of an injury by myself or anyone who may be attending my event.
46. Damages
    I understand by signing this form that I assume full responsibility for the condition of the room or rooms that I am renting from the Bentonville Parks and Recreation Department. I understand that if I don't return the room in the condition that it was before my event, Imay be charged for the cost of cleaning or repairs. By signing this form I understand that as the renter I am solely responsible for any damage that occurs to the room during my rental. I also understand that I am responsible for the actions of those who in attendance at the event for which I am renting the room.
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field