Event Application Form – Dickinson County Conservation Board

Sponsor Information

Contact Person*

First Last

Sponsoring Organization

Phone*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Email*

Event Website

Location of Event Official During Event*

List any co-sponsors or partners for this event:

Park Event General Information

County Park*

Name of Event*

Event Date(s)*

Alternate Date(s)

Event Primary/Starting Location in Park*

Event Start Time:*

End Time:*

Estimated Number of Participants*

Estimated Number of Spectators

Describe applicable area for the event: (include trail names/distance, picnic area, shelters, parking lots and similar facilities)*

Describe event activities:*

Identify items for the public or participants to bring: (lawn chairs, water, supplies, etc.)*

Will there be any registration/activity fees charged?*

Yes
No

Will there be a free will offering or donation?*

Yes
No

Will there be any food sold at the event?*

Yes
No

Will there be any items/goods sold at the event?*

Yes
No

Set Up / Tear Down Information

Will the sponsoring organization require access to the park between hours of 10 p.m. and 4 a.m. for event set up or tear down?*

Yes
No

Event Set Up Date

Set Up Start Time

Event Tear Down / Clean-Up Date

Clean-Up Start Time

Special Event Permit Requirement

Some qualifying events on Dickinson County managed parks, recreation areas, or state forest land may require a special event permit. If your event meets one of the following criteria, a special event permit will be required and you will need to complete the rest of the application:

1. An organized race, tournament, exhibition or demonstration, or other planned event in which an admission fee is charged, prizes are awarded, or competition occurs between participants
2. A planned event that, due to its nature, potential or actual size, or length, would likely adversely impact the use of the area by the public
3. An event in which there is a free will offering or donation request
4. An event in which private vendors will be selling food, souvenirs or other merchandise.

NOTE: Groups who co-sponsor/partner with the Dickinson County Conservation Board on an event must have a special event permit if you charge a registration/activity fee, accept donations or free will offering, fund raise, or invite private vendors to sell food and other items at the event.

Concession Information

Please list the names of the vendors and the type of concession (food, souvenirs, etc.)

Additional Information

Are you a participant in the State Lands Volunteer Program?*

Yes
No

Will there be a need to dig in the ground for any reason?*

Yes
No

If yes, please explain:

Will stakes be used in the ground?*

Yes
No

Will there be any tents larger than 30’ x 30’?*

Yes
No

Will any temporary equipment or structures be installed/placed on site?*

Yes
No

If yes, please describe

Will port-a-johns be required to accommodate the anticipated size of the event?*

Yes
No

Identify provider, estimated number of port-a-johns and location(s) where they will be placed.

How will trash collection and disposal be handled for the event?*

Will electricity be required for the event?*

Yes
No

How will safety or security be addressed for the event?*

Will the event utilize portable radios for communication?*

Yes
No

Describe how traffic and parking will be handled for the event:*

Will medical or fire personnel be on scene for the event?*

Yes
No

Name of department providing medical and/or fire support during the event

Is there an emergency response plan for the event?*

Yes
No

Insurance Carrier Name

Policy

Issuance Date

Comments

Consent*

I agree to the statement below:

The applicant understands and agrees that neither the State of Iowa nor the Dickinson County Conservation Board shall be responsible for any injury to persons or damage to property arising out of or incidental to the activities which are subject of this application. The applicant agrees by execution hereof to indemnify and hold harmless the State of Iowa and the Dickinson County Conservation Board against all liabilities, costs and expenses which may arise in consequence of the applicant’s activities related to this application being approved.

By checking this box, I certify that I made this application on this day and agree to be bound to the terms and conditions of the authorization and applicable law. Furthermore, I certify that the information contained in this application is true and accurate to the best of my knowledge, and I understand that the Dickinson County Conservation Board will revoke a permit if based upon false information.

Dickinson County Conservation Board will review the application and provide a written authorization or special event permit that outlines the terms and conditions for the event.

Dickinson County Parks Event Application Form

Sponsor Information

Park Event General Information

Set Up / Tear Down Information

Special Event Permit Requirement

Additional Information