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2. For Media Borough Residents Only - Please submit 30 days prior to event
4. Park*

   1. Trusty Tot Lot Picnic Tables & Lawn Area (3rd and Monroe Streets)
   2. Houtman Park (Park Avenue & Lincoln Street)
   3. Heritage Park (5th and Broomall Streets)
   4. Manchester Park (Manchester Avenue between Front and Baltimore)
5. 
7. First Name*
8. Last Name*
10. Address*
12. City*
13. State*
14. Zip Code*
16. Phone Number*
17. Email Address*
19. Date of Event*
21. Type of Event*

    1. Birthday Party
    2. Wedding
    3. Other
22. Time*

    1. 10 AM - Noon
    2. 1 PM - 3 PM
    3. 4 PM- 6 PM
24. Estimated Attendance *

26. If approved, applicant will be required to provide a certificate of insurance. Applicant agrees to indemnify and hold harmless the Borough of Media from any liability to any person resulting from any property damage or personal injury occurring in connection with the activity caused by the applicant. Applicant shall ensure that all parties involved in the event do not drive or park vehicles on grass. Applicant shall ensure that all parties involved adhere to the parking regulations of the Borough and are respectful of the surrounding neighborhood. No alcohol, tobacco products, glitter, sparkles, fireworks, rice, bird seed, etc. may be used and it is the responsibility of the person listed on this form to ensure that all event participants and spectators are notified of such. Fastening or attaching any rope, sign, banner, flyer or other object to any tree or shrub is prohibited. Media Borough does not provide amenities such as sound systems, tables, chairs, tents, portable washroom facilities or other support services and materials. Selling goods in Media Borough parks is prohibited and charging a fee to attend an event is not permitted. Applicant agrees to return the park to the state in which it was found. Please note this reservation does not prohibit others not with your party from using the reserved area.

28. Digital Signature*
29. Today's Date*
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field