Event Application Form Dickinson County Parks Event Application Form Sponsor InformationContact Person* First Last Sponsoring Organization Phone*Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Event Website Location of Event Official During Event* List any co-sponsors or partners for this event:Park Event General InformationCounty 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 InformationWill 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 RequirementSome 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 InformationPlease list the names of the vendors and the type of concession (food, souvenirs, etc.)Additional InformationAre 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 CommentsConsent* 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.