Date:________________________

Time:________________________

Number of People expected___________

Type of Facilities Requested: 

Bingo Building:   _____   Kitchen needed:_________

Field:  Pavilion:________Stage:_________Kitchen:_________Bathrooms:__________

Purpose:___________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Contact Name:______________________________________________________________

Contact Telephone:__________________________________________________________

Email address:_____________________________________________________________

Non-profit individuals and groups may use premises if available on a donation basis.  A certificate of insurance must be provided to Powhatan Volunteer Rescue Squad, Inc. prior to use.  All trash must be removed after event.  For groups of 25 people or more a County of Powhatan Special Event Permit must be completed and approved prior to the event.  This permit can be found on our links page by clicking on Parks & Recreation - County of Powhatan - Events Permit.

Please scan this form and email to:   facilities@powhatanrescue.com or print and fax to 804-598-4156 Attention:  Building & Grounds