House with Swimming Pool Rental Agreement - PDF

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					                                     MILSTONE 4-H CAMP
                                           Rental Agreement

This form should be completed, signed and returned to Millstone 4-H Camp, 1296 Mallard Dr.,
Ellerbe, NC 28338. A deposit of 50% (non-refundable) of the total estimated cost is required
with all rentals. 4-H reserves the right to utilize facilities to it’s fullest potential to maximize

Name of Group ________________________________________

Person in Charge (attending with group) _________________________________

Address ________________________________ Phone ____________________
City ________________________________ State _______ Zip ______________

Purpose of Event _____________________________________________________________

Choice of Dates 1st ______________________ 2nd ______________________________
Time Arriving _________________ Departing ______________________

*Expected Attendance Male _________ Female __________
*Please be conservative in your estimate of attendance. If there is a decrease in the expected attendance,
the Center Director must be notified 3 days prior to arrival or the group is obligated to pay 50% of the
difference from the total number specified above, plus the full amount for those attending.

**Please note. Linens and pillows are not furnished by the camp.

Meals:Provided by camp _______
            From ___________ on ____________ through ____________on ___________
                       (meal)                (date)                      (meal)             (date)

       Provided by rental group _________
             From ___________ on ____________ through ____________on ___________
                       (meal)                (date)                      (meal)             (date)

Total Estimated Cost (from page 2) $______________

Amount of Deposit $_____________

For Office Use
Deposit Paid                        Date                                 Check #
Rental Agreement
Page 2

                                                Pricing Worksheet

Facilities                                   Rate                         # Needed    Days/Hours      $ Amount
Dining Hall Only                             $75/day
Dining Hall with Kitchen*                    $250/day
Recreation Hall                              $50/day
Lentz Building                               $75/day
Rifle Range                                  $25/day
Archery Range                                $25/day
100 Yard Range                               $25/day
Swimming Pool (June-August)                  $100/day + lifeguards
Riding Rings                                 $25 ea/day
Stalls for Horses                            $5 ea./day
Canoes                                       $5 ea./day
Instructors/Lifeguards                       $15/hour
Ropes Course                                 $200/day + instructors
                                                                               Total for Facilities
*need to inquire about availability

Date               Breakfasts ($6)              Lunches ($7)                Dinners ($9)              Total
              #         Amount           #         Amount             #        Amount

                                                                             Total for Meals

Date            Cabins 4-H              Cabins Non            Staff House 4-H          Staff House       Total
                  ($10)                  4-H ($15)                  ($15)             Non 4-H ($20)
              #    Amount             #     Amount          #         Amount         #       Amount

                                                                                 Total for Lodging

Day Use Fees
Number of People________ X $3.00 per person = ________________

                                                          Total From Facilities ____________
                                                          Total For Meals       ____________
                                                          Total For Lodging     ____________
                                                          Total For Day Use     ____________
                                                                  Total ____________________
Rental Agreement
Page 3

Millstone 4-H Camp is dedicated to equal opportunity, and does not condone discrimination on
the basis of race, color, national origin, religion, age, sex, or disability. Disabled persons who
wish to participate in Camp activities may contact the Director regarding reasonable

I acknowledge that my use of the Camp and its facilities and services involves potential risks,
including the of injury, death, or property loss due to negligence or other causes. As part of the
consideration for being allowed by North Carolina State University and the Camp to use the
Camp facilities and services, and as an authorized representative of the Group, I agree that the
Group as well as me personally shall assume legal responsibility for all acts and omissions of,
and risks to, members, agents, and guests of the Group.

Furthermore, I hereby agree to indemnify and hold harmless the 4-H Youth development
program, 4-H employees and agents and the North Carolina State University, it’s trustees,
officers, employees, and agents from any and all negligence, claims, damages, and liability
arising form of related to activities of the Group and it’s members, agents, and guests while they
are at the Camp.

I am an authorized representative of the Group. I hereby accept the terms of this facilities use
agreement, as well as the Camp Regulations and the Liability Release and Indemnification, on
behalf of the Group.

Signature ______________________________ Printed Name _________________________

Date ______________________

N.C. 4-H Camps Approval ____________________________

Date ______________________
                           REGULATIONS CONCERNING THE USE OF
                                  MILLSTONE 4-H CAMP

Groups using the facilities at Millstone 4-H Camp are responsible for adhering to these guidelines.

   1. If a date is cancelled or there is a decrease in the expected attendance, the Director must be
      notified 30 days in advance. If not, a late cancellation fee off 50% will be accessed.

   2. The person submitting the application must arrive in advance of the group to register with the
      Director or his representative to help with the registration and orientation of the group upon
      arrival, as well as a facility walk through. This same person is responsible for the facilities and
      the conduct of the group.

   3. A charge will be made for breakage or loss of equipment (unless determined as normal wear).
      Groups are responsible to leave the camp clean and in order.

   4. Swimming and canoeing is permitted when:

           a. The group provides 2 currently certified American Red Cross Lifeguards to be on hand
              and responsible at each activity.
           b. Life jackets are worn while in canoes – no exceptions.
           c. Group is responsible for leaving canoes on racks, trailer, or in storage area. Paddles and
              life jackets are stored.
           d. Swimming is permitted in the swimming pool only.
           e. The Director will halt any activity that they consider to be unsafe.

   5. Parking is permitted in the parking lot only. Cars will not be permitted on the grass or around
      buildings. Cars cannot be driven to the cabins!

   6. No pets are allowed at the center.

   7. Phones – Messages will be taken for those staying at the center; however, due to the
      large area to be covered, these messages are delivered to the individual responsible for
      the Group. Calls may be make on the phones in the camp, one is located in the kitchen
      pantry and the other is in the staff house. Calls must be made either collect or with a
      calling card.

   8. Unless special arrangements are made in advance, rental groups are responsible for all
      program, staffing, and food service.

   9. No alcohol or illegal drugs are permitted on the premises.

   10. All groups are responsible for their own first aid needs.

   11. All groups are responsible for leaving all facilities clean and trash placed in the

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