Free Shelter Reservation Request - Indiana

PERMIT FOR SPECIAL EVENTS
Department of Natural Resources/Division of Forestry
State Form 50716 (12-01)

The Department of Natural Resources hereby grants permission to: Name: ____________________________________ Address: ____________________________________ City, State, Zip: ____________________________________ AC-Telephone: ____________________________________ To sponsor a special event (name of event): At (property name): Start date: ___________________ Description of event: _____________________________________ _____________________________________ End date: ___________________

_____________________________________________________________________________________ _____________________________________________________________________________________
Name of the Department's representative on site: The organization's representative shall be: _________________________________________

Name: Address: City, State, Zip: AC-Telephone:

____________________________________ ____________________________________ ____________________________________ ____________________________________

This permit is issued subject to the following special terms and conditions: 1) This area covered in this agreement shall be fully described below (additional pages may be attached):

2)

The following conditions and terms apply (additional pages may be added): (A)

(B)

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PERMIT FOR SPECIAL EVENTS
Department of Natural Resources/Division of Forestry
State Form 50716 (12-01)

3)

The participants in this event agree to abide by all the rules and regulations in general use on the property. The contemplated use of the land area shall be without cost, expense or obligation on the part of the State of Indiana. No permanent facilities or structures of any kind shall be constructed, erected or maintained.

4)

5)

6)

There shall be no interference with, nor any attempt made to forbid the full and free use by the public of the State Forest or facilities. Any interference with, damage to, or littering of property under the control of the State of Indiana due to the event herein granted shall be promptly corrected by the permittee to the satisfaction of the Property Manager.

7)

8)

Attached to the special events request, the sponsoring group shall file with the Indiana Department of Natural Resources a certificate of insurance. The Department may accept an insurance binder. The Department of Natural Resources must approve the insurance company providing the coverage. The certificate of insurance or insurance binder shall evidence that the sponsoring group has obtained an irrevocable general liability insurance policy providing for a limit of not less than $300,000 for all damages arising out of injury to or destruction of property in any one occurrence for a limit of not less than $100,000 for injury to or death of one (1) person in any one (1) occurrence and not less than $300,000 for injury to or death of all persons in that occurrence with the sponsoring group and Department named as insured. The sponsoring group shall indemnify, defend, exculpate and hold harmless the Department, its officials, employees, and agents from any liability due to loss, damage, injuries, or other casualties of any kind to the person or property of anyone arising directly or indirectly from the subject matter of the contract, whether due in while or in part to the negligent acts or omissions of the Department, its officials, agents or employees: or of the sponsoring group, its agents, employees, contractors or subcontractors; or the joint negligence of any of them including any claim arising under workmen's compensation or any other law, statute, regulation, ordinance, order or decree. This permit does not give any property rights, either in real estate or material or in any way contemplates exclusive use and such use will not in any way prevent, interfere or deny the public use and enjoyment of the area.

9)

Signatures needed on next page
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PERMIT FOR SPECIAL EVENTS
Department of Natural Resources/Division of Forestry
State Form 50716 (12-01)

Date Requested__________________

Organization Representative Signature__________________________

Date Signed____________________

Property Manager Signature__________________________________

Date Signed____________________

State Forester Signature_____________________________________

Date Signed____________________

DNR Director Signature_____________________________________

cc:

Permitee (1) Property Manager (1) Central Office File (1)

Additional Dates Check one: Special Events Vendors Permit

Signature___________________________________

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