PICNIC PERMIT APPLICATION

(FY 2015)

Present Date

ElmhurstParkDistrictRegistrationOffice
WagnerCommunityCenter(630)9938901Fax(630)9938929

ApplicantInformation
NameofApplicant:_________________________________________

Email:___________________________________________

Address:_________________________________________________

City/Zip___________________________________________

Telephone:(Home)_________________________________________ (Cell)_____________________________________________

Organization:_____________________________________________

Contact:___________________________________________

Telephone:________________________________________________

Email:____________________________________________

AddressofOrganization:____________________________________

City/Zip:___________________________________________

PicnicInformation
ReasonforPermit:___________________________________________________________________
Date:1stchoice:_________________

Mark1st,2nd,
and3rdchoice

Park

PicnicArea

BerensPark

Area4Red
Area3Yellow
Area10Blue
Shelter9Red
Area1Red
Shelter3Green
Area5Yellow
Area6Blue
Area7Green

ButterfieldPark
SaltCreekPark
WilderPark

2ndchoice:_________________

3rdchoice:_________________

Capacity

PicnicTables

Grills

Barrels

Weekday
DailyFee

Weekend
DailyFee

35
75
75
50
50
150*
50
50
50

7
20
20
15
15
35
10
10
10

1
1
1
1
2
2
2
1
1

2
4
4
3
2
6
2
1
2

$0R/$95NR
$0R/$95NR
$0R/$95NR
$0R/$125NR
$0R/$95NR
$0R/$125NR
$0R/$95NR
$0R/$95NR
$0R/$95NR

$54R/$95NR
$54R/$95NR
$54R/$95NR
$77R/$125NR
$54R/$95NR
$77R/$125NR
$54R/$95NR
$54R/$95NR
$54R/$95NR

Restroomsareavailablewithinwalkingdistancefromalldesignatedpicnicareas.

No.ofpeople*:____________________*Groups100attendeesormorewillberequiredtoobtainaSpecialUsePermit.
Timearriving:___________________AM/PM

AdditionalItems

Timedeparting:_________________AM/PM

*Ifyestoanybelow,acertificateofinsurancenamingtheParkDistrictasanadditionalinsuredpartyisrequired.

Areyouinstallingatemporarystructure(i.e.tentslargerthen10x10withtentstakes,stages,bleachers,etc.)duringyourparkusage?
(Circleone)YESNOIfYESexplain:________________________________________________________________________

Areyouhavingspecialactivities,demonstrationsand/orentertainment(moonjumps,etc.)duringyourparkusage?
(Circleone)YESNOIfYESexplain:________________________________________________________________________

Waivers

IfullyunderstandthatalcoholisprohibitedandsmokingisrestrictedinoronanyDistrictproperty. __________________(Initial)

Ihavereadandfullyunderstandtheimportantinformation,warningofrisk,assumptionofriskandwaiverandreleaseofallclaims.(describedonthereverseside)

______________________________________________

________________________________

(Signatureofapplicant)

(Date)

THEPARKDISTRICTDOESNOTGRANTREFUNDSDUETOWEATHERCONDITIONSORCANCELLATIONS

PaymentInformation

PaymentsAccepted:Cash,Check,orCreditCard

CreditCardPayment

NameofCardholder:______________________________________

ExpirationDate:_____/______/______

Discover,VISAorMasterCardonly

AuthorizedSignature:_____________________________________

ChargeAmount:$__________________

________________________________________________________________

For office use only

Approved by: ________________

Date: ________________

Office ________________

Permit # ________________

Picnic Area Regulations

Picnic Area regulations are applicable in all designated group areas and shall be posted as follows:
All rules and regulations must be observed and the directions of the Park District ambassador or his/her representative must be followed. Permit
holders are responsible for planning and supervising the event in accordance with District ordinances. Failure to do so may result in withholding
future permits, arrest or fines.
1.

Group picnicking is allowed only in designated group picnic areas. A special use permit is required for picnics with 100 or more
attendees.

2.

Designated picnic areas are marked. Picnic tables are not to be removed from their designated area.

3.

Permit holders have priority over groups without a permit. If a non-permitted group is using a permitted designated area, the permit holder
should present the permit and politely ask that the other group vacate the area. If a problem occurs, contact the Park Ambassador at
(630) 675-4491 or the Elmhurst Police at 911.

4.

Parking / driving is permitted only on designated roadways and parking areas. DO NOT DRIVE ONTO PARK GROUNDS.

5.

Alcoholic beverages are prohibited in all District parks and facilities.

6. Fires are permitted only in the picnic grills provided by the District in each group picnic area or in Portable Grills provided by the user.
Charcoal grills are only permitted in locations with coal bins. To prevent fires and damage to Property, wood fires and fire pits are
prohibited on District Property. Portable Grills cannot be placed onto picnic tables and must be completely extinguished with the coals
placed in the coal bins provided by the District before leaving the site. Campfires, barrel grills and grills with 20 pound or larger tanks are
prohibited on all District Property.
7.

Litter should be collected and placed in litter barrels before leaving. The permit holder is responsible for leaving the picnic area in a clean
and orderly condition. You may not be the last picnic of the day. Please be considerate of the next group.

8.

Electronically amplified sound is prohibited in Elmhurst Park District parks.

9.

Use of a temporary structure (tents larger than 10' by 10' with tent stakes, stage, bleachers, etc.), providing special activities (moonwalks, dunk
tanks, etc.), or having caterers deliver, prepare and/or serve food in the park requires appropriate certificates of insurance naming the Elmhurst
Park District as an additional Insured.

10. The use of all tobacco products is prohibited inside District buildings, within 20 feet of playgrounds, and within 20 feet of participants in or
spectators of organized District or affiliate group programs and events.
11. Photos and videos are periodically taken of people participating in Park District programs and activities. All persons registering for Park
District programs/activities, or using Park District property thereby agrees that any photograph or videotape taken by the Park District may be
used by the Park District for promotional purposes including its promotional videotapes, brochures, flyers and other publications without
additional, prior notice or permission and without compensation to the participant.
12. Parks close at dusk.

WAIVER & RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISK

Please read this form carefully and be aware that in signing up and participating in the Elmhurst Park District program(s) for which
you/your child are registering or will register during the next 12 months, you will be expressly assuming the risk and legal liability and
waiving and releasing all claims for injuries, damages or loss which you or your minor child/ward might sustain as a result of
participating in any and all activities connected with and associated with said programs/activities (including transportation
services/vehicle operation when provided).
I recognize and acknowledge that there are certain risks of physical injury to participants in these programs/activities and I voluntarily
agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that my minor child/ward or I may sustain
as a result of said participation. I further agree to waive and relinquish all claims I or my minor child/ward may have (or accrue to me
or my child/ward) as a result of participating in these program/activities against the Elmhurst Park District including its officials,
agents, volunteers and employees (hereinafter collectively referred to as Elmhurst Park District).
I do hereby fully release and forever discharge the Elmhurst Park District from any and all claims for injuries, damages, or loss that
my minor child/ward or I may have or which may accrue to me or my minor child/ward and arising out of, connected with, or in any
way associated with these programs/activities.
FY 2015