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Special Use Permit

Name of Event
Date of Event
Time of Event: Begin Time
End Time

Location of Event
No. of Participants
No. of Spectators
Description of Event
Will the event interfere with/impede normal use of area by the public?
Name of Sponsoring Organization
Address
City
State
Zip Code

Name of Applicant
Address of Applicant
City
State
Zip Code

Phone Number
Bus. Ph

Location of Applicant During Event
Special Conditions or Restrictions

Applicant's Statement

Applicant agrees to leave the used site in the same condition as found, cleaning up all litter and debris after event. Applicant is responsible for any damages to county property during the event either by participants or spectators. Applicant agrees to abide by all state laws and Jackson County Conservation Board rules and regulations.

The undersigned applicant for a special event permit understands and agrees that neither the Jackson County Conservation Board or Jackson County will be responsible for any injury to persons or damage to property arising out of or incident to the activities which are the subject of this application. The undersigned applicant agrees by the execution hereof to indemnify and hold harmless the Jackson County Conservation Board against all liabilities, costs and expenses which may arise in consequence of the granting of this permit.

The undersigned has full authority to represent the sponsoring organization:

Signature Please type your full name to serve as an electronic signature.
Title
Complete Address
City
State
Zip Code

Conservation

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Special Use Permit