SPECIAL EVENT APPLICATIONFOR AN ORGANIZATION
Organization Type
Profit
Non-Profit
501(c) (3) Entity number if Non-Profit
Note:
Applications should be submitted a minimum of 60 days before the event to allow adequate time to process, should it be necessary to go to the planning commission.
Title of Event:
Type of Event:
PROCESSION
WALK-A-THON
Other
SPONSOR OF EVENT AND CONTACT PERSON:
Contact Person:
First Name
Last Name
Phone Number:
Format: (000) 000-0000.
Fax Number:
Format: (000) 000-0000.
Name of organization:
Mailing address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date(s) of event:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hours of the event:
Hour Minutes
AM
PM
AM/PM Option
Location(s) of the event in Pocahontas:
Contact person day of event (if different than above):
First Name
Last Name
Phone Number:
Format: (000) 000-0000.
Fax Number:
Format: (000) 000-0000.
PLEASE ANSWER THE FOLLOWING QUESTIONS:
This event will be a
public event
private event (invitation only)
Total number of participants and visitors expected per day:
Description of activities:
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A deposit of $200 could be requested when application is approved. The Deposit will be returned if cleanup of facility is approved by City. Any additional charges incurred in cleaning or repair any damages as a result of the use of the facility will be assessed against the person/organization who submitted the application.
Will an entry fee, admission charge, door charge, ticket sales or Donation be taken to attend the event?
Yes
No
Will outside equipment be brought in for use for the event?
Yes
No
if yes, then please describe how the floor and the facility will be protected from its use during the event.
Parking plan (if applicable):
Type of advertising do you plan to do:
If this is a procession event, please attach route showing all locations in Pocahontas of sign postings, monitor locations, rest stops, etc.
Will there be a need for directional signs?
Yes
No
Will there be a need for security or traffic control?
Yes
No
If yes, please describe what is needed and how you propose to meet the need. Such as armed or unarmed, number of security officer's onsite, security company, etc.
Security
– An indication of what security measures will be taken for crowd control must be submitted. Include the number of employees and the number of security officers that will be used to supervise the event. This must be approved by the Chief of Police.
Do you plan on food and drink being available for sale?
Yes
No
If yes, please inform the City of how many people they can expect since the City will be in charge of concessions and will keep the proceeds from the sale of concessions. No outside vendors allowed.
Profit Event-If the event is on public property, attach certificate of insurance and for the event in the amount of at least $1,000,000 naming the City of Pocahontas as additional insured.
Will there be amplified music or voice?
Yes
No
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AGREEMENT AND RELEASE FROM LIABILITY
Voluntary Participation
1. I, [name of releaser] acknowledge That I have voluntarily applied to the City of Pocahontas for a special event for a
First Name
Last Name
For-profit
nonprofit organization.
The event is a
[describe event] to be held on
[date of event]
-
Month
-
Day
Year
Date Picker Icon
in the City of Pocahontas.
Assumption of Risk
2. I AM AWARE THAT THE ACTIVITY DESCRIBED ABOVE IN WHICH I AM ENGAGING MAY INVOLVE SOME RISK OF INJURY TO ME OR TO MY PERSONAL PROPERTY. I AM VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES WITH KNOWLEDGE OF THE DANGER INVOLVED, HEREBY AGREE TO ACCEPT ANY AND ALL RISKS OF INJURY, DEATH, OR PROPERTY DAMAGE AND VERIFY THIS STATEMENT BY PLACING MY INITIALS HERE:
Initials
Release and Hold Harmless Agreement
3. As consideration for being permitted by the City of Pocahontas to participate in these activities and use their facilities, I hereby agree that I, my assignees, heirs, distributes, guardians, and legal representatives will not make a claim against or sue the City of Pocahontas or any of its elected officials, employees, agents or attorneys for any injury or damage resulting from the negligence or other acts, howsoever caused, by any elected official, employee, agent, attorney or contractor of the City of Pocahontas as a result of my participation in the activity described above. I hereby release the City of Pocahontas, its elected officials, employees, agents, attorneys or contractors from all actions, claims or demands that I, my assignees, heirs, distributers, guardians and legal representatives now have or may hereafter have for injury or damage resulting from my participation in the above described activity. I expressly agree to indemnity and hold harmless the City of Pocahontas from and against any and all claims, loss, damages, injuries and
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liabilities, however caused. Resulting from or arising out of or any way connected with the use of City of Pocahontas facilities and property.
Knowing and Voluntary Execution
4.
I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN MYSELF AND THE CITY OF POCAHONTAS AND SIGN IT OF MY OWN FREE WILL.
Executed at
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Arkansas, on
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
RELEASER
Signature of releaser
Title
Declaration of Witness
I certify that
First Name
Last Name
presence that
Executed at
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Arkansas, on
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of witness
Title
Street Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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***************************************************
FOR STAFF REVIEW ONLY:
DATE APPLICATION RECEIVED:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
APPLICATION RECEIVED BY:
First Name
Last Name
FEE: $75.00 DEPOSIT: $200 PAID:
YES
NO
EVIDENCE OF INSURANCE/HOLD HARMLESS AGREEMENT ATTACHED
YES
NO
DEPOSIT FOR CITY SERVICES RECEIVED (IF APPLICABLE)?
APPROVAL:
BUILDING OFFICIAL APPROVAL NEEDED?
YES
NO
POLICE REVIEWED:
PUBLIC WORKS REVIEWED:
BUILDING DEPARTMENT REVIEWED:
PLANNING COMMISSION APPROVAL REQUIRED?
YES
NO
SPECIAL CONDITIONS OF APPROVAL:
DATE APPLICATION APPROVED:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
BY:
First Name
Last Name
Revised (2025)
6
what type of medical services will you be providing?
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