Application for Use of Facilities

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Executive Summary

This document outlines the application process for using facilities within Upper Township. It details the requirements for applicants, including providing event details, insurance certificates, and adherence to township policies. Applicants must complete the form, specifying the facility, date, time, and purpose of use, and agree to the Use of Facilities Agreement, which includes indemnification and insurance obligations.

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--- Document: Application for Use of Facilities Document ---
Upper Township 
PO Box 205 
Tuckahoe, NJ  08250 
609-628-2011 Ext. 200 Main Office
Application for Use of Facilities 
Name of Event: __________________________________________ Number of attendees: ____________ 
Applicant/Organization:  __________________________________________________________, if more 
than one person or entity, jointly, severally and in the alternative. 
Address: 
     City: 
State: 
 Zip Code: _______ 
Person Responsible: 
Name: _____________________________________ Title: ______________________________________ 
Address: 
     City: 
State: 
 Zip Code: _______ 
Telephone: (H) __________________ (C) _________________ Email: _____________________________ 
The Applicant requests the use of the facilities listed below: 
Name and Location of Facility (ies): _______________________________________________________ 
Area Requested: _________________________________________________________________________ 
Community Center: 
Multi-purpose room_________ Gym_________ and/or Refreshment stand__________ 
(Keys to the Community Center must be obtained from the Recreation office prior to the event during regular business hours M-F 7:00-3:00 p.m.) 
Equipment and/or Special Requests: _______________________________________________________ 
For the following purpose, (describe in detail): _________________________________________________ 
______________________________________________________________________________________ 
On the following date(s): (please include month, day, year)  Start Date: __________ End Date: __________
NOTE: Attach Schedule if multi-day event 
Specify the hours of use: (allow for setup & breakdown) 
Time: From: _________________To _____________________ 
For Township Use Only 
Received by:___________ 
Date received: ________ 
Date Cc to PW: ________ 
Approved by: __________ 
Resolution No.:_________ 
For questions regarding this form please contact the Upper Township Sports & Recreation Office at 609-628-2011 ext. 248 or email recreationdepartment@uppertownship.com. 
Revision date: 2/2/24
Page 1


Will juveniles be present? Yes ____ No  _____ If Yes, what ages? _______________________________  
If juveniles will be present, the Applicant must submit the names, addresses, and telephone numbers of 
chaperones prior to event. 
Please note:  The serving of alcoholic beverages at any Township facility is strictly forbidden. 
Insurance Certificate:  Attach a copy of certificate of insurance coverage for this activity naming the 
Township of Upper as Certificate Holder, and Additional Insured and other requirements as specified on 
attached Exhibit B. Insurance Certificate -- ______Attached 
I have received a copy of the Municipality Use of Facilities Agreement and I agree to abide by and comply with the 
terms of that Agreement.  I hereby certify that the facility will be used in accordance with Upper Township Policy.  I 
further agree to hold harmless Upper Township for any injury or loss arising from the use of this facility. 
______________________________________ DATE: ________________________ 
Signature 
 ______________________________________ 
Print Name and Organization
If more than one person or entity 
Signing individually and as __________________ of ___________________________________________ 
Title 
Name of Organization 
Note:  Municipality has the right, in its sole discretion, to deny, limit, or revoke the use of requested facility (ies) when in the opinion of the 
Municipality the use presents a risk of unreasonable injury to persons or damage to property of the Municipality or others. 
For questions regarding this form please contact the Upper Township Sports & Recreation Office at 609-628-2011 ext. 248 or email recreationdepartment@uppertownship.com. 
Revision date: 2/2/24
Page 2
SIGN


EXHIBIT A 
Use of Facilities Agreement 
Upper Township, PO Box 205, Tuckahoe, NJ 08250, a Municipality of the State of New Jersey, 
hereinafter referred to as “MUNICIPALITY”, hereby agrees to allow:  
____________ 
(Name of Person(s) and Organization), if more than one person or entity, jointly, severally and in the 
alternative. 
Hereinafter referred to as “USER”, to use the facilities listed below: 
(Name and Location of Facility(ies) 
Hereinafter referred to as “FACILITY (IES)” 
For: 
(State the Purpose) 
on the following date(s): 
The above USER shall inspect the described FACILITY(IES) prior to the use of the FACILITY 
(IES) and report any defective, hazardous or dangerous conditions found at the FACILITY(IES) 
to:          
Recreation Department-609-628-2011 Ext. 248, or
Clerk’s Office 609-628-2011 Ext. 200, 
USER shall immediately cease the use of the FACILITY(IES) until such defective, hazardous or 
dangerous conditions are remedied.  After the use of the FACILITY(IES), USER shall 
immediately report to the MUNICIPALITY any and all defects, hazards, damages or dangerous 
conditions upon or adjacent to the FACILITY(IES).  
INDEMNIFICATION 
USER shall indemnify, save harmless and defend the MUNICIPALITY, its elected and appointed 
officials, its employees, agents, volunteers and others working on behalf of the MUNICIPALITY, 
from and against any and all claims, losses, costs, attorney’s fees, damages, or injury including 
death and/or property loss, expense claims or demands arising out of USER’s use of the named 
Facilities, including all suits or actions of every kind or description brought against the 
&
For questions regarding this form please contact the Upper Township Sports & Recreation Office at 609-628-2011 ext. 248 or email recreationdepartment@uppertownship.com. 
Revision date: 2/2/24
Page 3


MUNICIPALITY, either individually or jointly with USER for or on account of any damage or 
injury to any person or persons or property, caused or occasioned or alleged to have been caused by, 
or on account of, any of the activities conducted by or caused to be conducted by USER, or through 
any negligence or alleged negligence in safeguarding the FACILITY(IES), participants, or 
members of the public, or through any act, omission or fault or alleged act, omission or fault or 
alleged act, omission or fault of the USER, its employees, agents, volunteers, subcontractors or 
others under the direction, control or under any contractual relationship with the USER. 
Insurance 
Notwithstanding the indemnification and defense obligations of the USER, USER shall purchase 
and maintain such insurance described in the attached schedule (Schedule B) and as is appropriate 
for the type of use and hazards present and as will provide protection from any and all covered 
claims which may arise out of or caused or alleged to have been caused in any manner from 
USER’s use of the FACILITY(IES), whether it is to be used by the USER, its employees, agents, 
volunteers, subcontractors or others under the direction, control or under any contractual 
relationship with the USER or by anyone for whose acts any of them may be liable. 
USER shall be required to name the MUNICIPALITY as an “Additional Insured” on the USER’s 
policy of commercial general liability insurance, and simultaneously with the delivery of the 
executed Use of Facilities Agreement (Exhibit A), USER shall provide the MUNICIPALITY with 
a Certificate of Insurance indicating that the insurance coverage as described in the attached 
schedule (Exhibit B), and as is appropriate for the type of use and hazards present, has been 
obtained and that the MUNICIPALITY has been designated as an “Additional Insured” where 
required (see Exhibit B for required wording).  On or before the renewal date of said policy, USER
shall be required to provide the MUNICIPALITY with a Certificate of Insurance indicating the 
continuation of insurance coverage and designating the MUNICIPALITY as an “Additional 
Insured” for the duration of this agreement.  
The schedule of insurance and the limits of liability for the insurance shall provide coverage for not 
less than the amounts listed in the attached schedule or greater where required by law.     
Signed by an authorized representative of the USER and the MUNICIPALITY on this _____ day 
of _______________, 20_____. 
USER: 
Signature ____________________________ 
____________________________________ 
__________________________________ 
Print Name 
Township of Upper 
If more than one person or entity 
__________________________________ 
signing individually and as 
Witness 
_________________________________ 
Title 
of________________________________ 
Name of Organization 
____________________________ 
Witness 
For questions regarding this form please contact the Upper Township Sports & Recreation Office at 609-628-2011 ext. 248 or email recreationdepartment@uppertownship.com. 
Revision date: 2/2/24
Page 4
SIGN
January 


EXHIBIT B
Schedule of Insurance* 
Notwithstanding the indemnification and defense obligations of the USER, the USER shall provide at its 
own cost and expense proof of the following insurance to the “MUNICIPALITY”: 
General Liability including Products & Completed Operations Insurance 
with a minimum combined single limit of liability per occurrence for bodily injury and property 
damage of one million ($1,000,000) dollars* with a minimum annual aggregate of two million 
($2,000,000) dollars*. 
MUNICIPALITY shall be named as an “Additional Insured” which must read as follows: 
“Township of Upper, including all elected and appointed 
officials, all employees and volunteers, all boards, 
commissions and/or authorities and their board members, 
employees and volunteers.” 
Failure by the USER to supply such written evidence of required insurance and to maintain same for 
the duration of this agreement shall result in default of this agreement and USER shall be prohibited from 
using said FACILITY (IES).                                                                                                       
The insurance companies for the above coverage must be licensed by the State of New Jersey and 
acceptable to the MUNICIPALITY.  The USER shall take no action to cancel or materially change 
any of the insurance required under this Contract without the MUNICIPALITY’s prior approval.  The 
maintenance of insurance under this section shall not relieve the USER of any liability greater than the 
limits or scope of the applicable insurance coverage. 
For questions regarding this form please contact the Upper Township Sports & Recreation Office at 609-628-2011 ext. 248 or email recreationdepartment@uppertownship.com. 
Revision date: 2/2/24
Page 5

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"...________________ (C) _________________ Email: _____________________________ The Applicant requests the use of the facilities listed below: Name and Location of Facility (ies): _______________________________________________________ Area Requested: _____________________________________________________________________..."

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