Today's Date* MM slash DD slash YYYY Organization Name* Purpose of Organization*Date of Meeting* MM slash DD slash YYYY Meeting Begin Time* : Hours Minutes AM PM AM/PM Meeting End Time* : Hours Minutes AM PM AM/PM Intended Use and Special Requests*Number of persons expected at meeting*Name of Contact Person* Organization Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Phone (Day)*Phone (Evening)*The meeting will be free. (This must be checked in order for your group to meet.)* Yes Check here if your meeting is grant related and/or requires a letter of commitment. Yes Agreement* I understand the policies for use of the Classroom at Dare to Care. I understand that our use of the meeting room may be cancelled if these policies are not followed.Agreement for Private Use of Dare to Care Community Kitchen Classroom This Agreement is between Dare to Care (DTC), and the appropriate Responsible Party (RP) as designated by their signatures below. The RP shall be the organization or individual leasing the Premises. If the organization is not a legal entity, then the group shall appoint a person to act as the RP on behalf of it and that person shall be individually liable for performance under this agreement. Services to be Performed by DTC DTC will provide the room, tables, chairs, and directions for using any available audio-visual equipment/WiFi, if requested in advance. Damage and Clean-up Fee RP shall be obligated to maintain the Premises both inside and outside in the same condition existing before use. RP shall also be obligated to repair any damage to the premises. A clean-up and usage fee of $75 will be assessed if the room is not cleaned after use and must be paid by RP seven days after use. Conduct DTC requires RP and guests to act in a publicly acceptable manner and to abide by the directions of DTC associates and security personnel while on the Premises. Meetings must be non-partisan and in-line with DTC’s mission and values. DTC has the authority to terminate any activity at the Premises found to be destructive or otherwise objectionable in DTC’s discretion. Smoking Smoking is prohibited throughout the entirety of the building. Weapons Weapons are prohibited. Restrooms There are two restrooms available to RP and RP’s guests. Indemnification All groups or individuals reserving a meeting room acknowledge that they understand and agree with the following indemnification statement: In consideration of Dare to Care allowing me to use the facilities, I hereby waive and release Dare to Care and their officers, agents, employees, and volunteers from all claims or causes of action for injury, damage or loss to my person or property during my participation in the event. I hereby further agree to indemnify, hold harmless and defend Dare to Care and their officers, agents, employees, and volunteers from all losses, claims, or causes of action for injury, damage or loss in any way relating to or arising from any incidence occurring during the event. This waiver and release are intended to be an express waiver of and release from all claims against Dare to Care and their officers, agents, employees, and volunteers arising from the event, including all claims or causes of action based upon the alleged negligence or gross negligence of Dare to Care and their officers, agents, employees, and volunteers. I expressly agree that this Permission, Release, Waiver, and Indemnification agreement shall be interpreted as releasing Dare to Care and their officers, agents, employees, and volunteers from all liability and claims to the fullest extent allowed by the laws of Kentucky. Name* Title* CAPTCHA