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2. 
3. Area of Building Requested:*
4. Date(s) Requested:*
6. Time Requested: {From this time to this time}*
8. The Facility will be used for the following purpose(s):*

10. The undersigned individual on behalf of itself and the organization(s) it represents (hereinafter the “Undersigned”) acknowledge that it has reviewed and agrees to comply with the St. Joseph County County Building Usage Policy.  

    The Undersigned agrees to pay the fee for St. Joseph County Sheriff officers or contracted contracted county security officers should the Commissioners determine that officers are required for the event. The fee is $60 per officer per hour with a four (4) hour minimum. The County shall determine in its sole discretion if and how many officers will be required. This fee shall be paid in full at least 7 days before the date of the event or the event reservation will be automatically terminated.

    The undersigned agrees that the undersigned will assume responsibility for the repair, replacement or cleaning of any St. Joseph County premises and/or property which might be damaged during the license period. 

    The undersigned further agrees that Licensor shall not be liable for any personal injury or property damage occurring on or to the premises or to any persons or property in or on the premises, whether negligent or otherwise. Licensee shall not make any claim against Licensor for any loss or damage described in this section. 

    Licensee hereby releases Licensor from any and all actions, causes or actions, claims and demands for, upon or by reason of any damage, loss or injury, which hereafter may be sustained. This release, extends and applies to, and also covers and includes, all unknown, unforeseen, unanticipated and unsuspected injuries, damages, loss and liability and the consequences thereof.

    The undersigned agrees to defend and indemnify St. Joseph County and its employees, officials, elected officers and assigns against any and all claims which arise in whole or in part as a result of the use of the building.

    The undersigned warrants that it is authorized to enter into this agreement as an agent of the organization(s) listed below and to bind the organization to the same.

    The Statements and agreements herein are not merely recital but are contractual in nature.  

12. First Name:*
13. Last Name:*
15. 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.
17. Electronic Signature*
19. Address:*
21. City:*
22. State:*
23. Zip Code:*
25. Cell Phone:*
26. Email:*
28. Rental Fee:
29. Deposit:

31. Please return forms and fees to: St. Joseph County, c/o Cara Alderfer, 227 W Jefferson Blvd, South Bend, IN 46601

     

     

    The Following is for County Use Only:

    Date Received:                                                 By:                                            

    Agenda date:                                            Approved/Unapproved

    Number of Officers Required:_________________________________________

    Special Requirements:                                                                                                                      

    
    

    
    

    ______________

    Carl H. Baxmeyer

     

    ______________

    Deborah A Fleming, DMD

    
    

    ______________

    Derek D. Dieter

Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

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