44 McCombe AvePh: (08) 9331 8040
SAMSON WA 6163Fax: (08) 9331 7051
Details of Hirer
Name of Organisation/Hirer
Type of Organisation (e.g. sporting club,
community group, commercial organisation, etc)
Name of Contact Person
Postal Address
Contact Person’s Telephone Numbers(H) (W)
(Mobile) (Email)
Details of Hire - Programme/Function
Rooms Required
Day and Date Required
Time RequiredStart End
(time booked will be charged for - includes set up and take down time)
Times of Actual Event (if different)
Description and Purpose of Event
Number of participants
Additional Equipment Required
Will the general public be involved?YES/ NOIf YES, expected number
If the booking is a function/event – please answer the following:
Will an entrance fee be charged?(Approval Must Be Sought From Council)YES/ NO
Is it a fundraising event?YES/ NO
If YES, which organisation(s) will benefit?
The Samson Recreation Centre is a smoke and alcohol free venue.
Please Turn Over
Other Details
What will you be bringing into The Centre (e.g. PA, extra lighting, amusements, advertising banners, etc)?
Will any equipment be secured to the ground, or walls, etc? YES/ NO
Food and Drinks
Will food or soft drinks be for sale during the event/activity?YES/NO
(City of Fremantle Temporary Food Permit is required if the public is involved)
If YES please list vendors and type of food/drink for sale and license numbers
If the event is considered large scale professional security must be contracted. This may be up to the discretion of Centre Management. A copy of receipt and information must also be forwarded to Council.
First Aid
The City of Fremantle recommends hirers to bring some basic first aid equipment where appropriate. Ice is available in the freezer for sports related injuries.
General Information
Please supply any other information about your application and any additional requirements you may have.
Public Liability Insurance
The City of Fremantle recommends hirers to take our public insurance liability to protect their group from any damage or injury that may occur during their function. The City will provide a duty of care to provide a safe environment but agrees the City is not responsible unless proved negligent. If there is the potential for any damage that could have been reasonably foreseen and does occur then the City of Fremantle retains the right to pursue a claim for damages from you the Hirer.
Please sign as having received a copy of the Hire Induction Package and/or Conditions of Hire and agreeing to abide by the listed conditions.
Name Signature
Indemnity Attached Yes NoDate
ONCE COMPLETE PLEASE RETURN TO;
Samson Recreation Centre Bookings
(Attn: Richelle Gandy)
City of Fremantle
PO Box 807
FREMANTLE 6959
1