ACTIVITY REQUEST

Hunterdon Conservation Education and Recreational Council Inc.

ROUND VALLEY YOUTH CENTER

P.O. BOX 424

LEBANON, N.J. 08833

NAME OF ORGANIZATION______________________________________________________________

GROUP LEADER_______________________________________________________________________

PHONE#____________________________

EMAIL ADDRESS______________________________________________________________________

WHAT COUNTY DOES THIS GROUP REPRESENT ?_____________________________________________

DATE (S) REQUESTED___________________________________________________________________

NUMBER OF PERSONS ATTENDING________________________ (office use only U/D)_______________

NATURE OF USAGE_____________________________________________________________________

INSURANCE CERTIFICATE _______________________________________________________________

FACILITIES DESIRED:

CAMPING AREA _______________                            POND_________________

PICNIC AREA_______________

NATURE TRAILS__________________                       HORSE RINGS____________

HAY RIDE______________                                      PAVILION________________

CHECK HERE IF YOU PLAN TO BUILD FIRES IN THE CAMPING AREA.____________

CHECK IN (DATE / TIME) ____________________________________________

CHECK OUT (DATE / TIME)___________________________________________

YOU, AS THE GROUP LEADER, SHOUD BE THE FIRST TO ARRIVE AND THE LAST TO LEAVE.

IF THIS IS NOT POSSIBLE, DELEGATE RESPONSIBILITY TO ANOTHER ADULT MEMBER OF

YOUR GROUP BELOW:

NAME ___________________________________________________________________

PHONE#____________________________

I certify that the above information is correct and that I am an authorized adult leader of

this group/organization. I acknowledge receipt of the Rules and Regulations with which

we will comply.

SIGNATURE OF LEADER _______________________________________________

DATE___________________________________

THIS PERMIT GRANTS NO PRIVILEGES OTHER THAN THAT WHICH IS SPECIFICALLY STATED HEREIN. IT MAY BE

REVOKED OR MODIFIED BY THE ROUND VALLEY YOUTH CENTER SHOULD IT BE DEEMED NECESSARY.

PLEASE LEAVE THE AREA AS CLEAN AS YOU FIND IT.

THE HUNTERDON CONSERVATION, EDUCATION, AND RECREATIONAL COUNCIL INC.

(ADMINISTRATORS OF THE ROUND VALLEY YOUTH CENTER), DEPENDS UPON YOUTH

GROUPS USING THE CENTER TO HAVE PARENTAL PERMISSION AND ALL GROUPS TO

PROVIDE PROOF OF INSURANCE COVERAGE. THE COUNCIL DOES NOT ASSUME THIS

RESPONSIBILITY.

THE ROUND VALLEY YOUTH CENTER OPERATES FOR THE MOST PART THROUGH

INDIVIDUAL AND GROUP DONATIONS. WE NEED A STEADY INCOME FROM DONATIONS

TO REMAIN OPEN TO ALL YOUTH ORGANIZATIONS.  PLEASE HELP IF YOU CAN.

(Rev 3/25/06)