Name of Applicant or Representative:

Phone:    Please provide a phone number that will reach you on the day of the event.
Address:
City: State: Zip:

Name of Organization Represented (if applicable):
Title/Subject/Purpose of Activity:
Number of Individuals Participating in this Activity:

Category of Nonprofit Activity (check applicable):
Government
Private - County-Based Nonprofit Organization
Private - County Employee
Private - County Resident

Requested Date and Time of Activity:
Date: From: To: Please indicate a.m. or p.m.
        (If Multiple Dates are needed, please email entire requested list to Donna.Slaymaker@fairfaxcounty.gov)

Will Food/Drinks be served?* Yes No. If Yes, describe:
*Only light refreshments such as bottled water, coffee, and tea are allowed.

Notes (for example, room preference, recurring event dates, etc): 

You must bag and remove trash, and you must keep noise level low to avoid disturbing staff in offices adjacent to the community room and in the police station.  Excessive noise may result in your group being asked to leave immediately.  Activities may not be conducted in the hallway or lobby without express prior permission.  Make sure room is clean and lights are off when finished.  Violation of any rules or conditions may revoke your privilege to use of the room in the future.

Permission granted for use of any portion of the facilities and/or grounds at a Fairfax County District Governmental Center by any organization or individual may be revoked, canceled, postponed, or rescheduled.

NOT PERMITTED AT THIS FACILITY:  Fundraisers, weddings (with the exception of ceremonies performed by a Celebrant), wedding receptions, boisterous parties, singing, instruments, radio, or amplified music of any kind.

I accept liability and hereby agree to indemnify and hold harmless the County of Fairfax, Virginia, its officers, agents and all employees and volunteers, from any and all claims for bodily injury, personal injury and/or property damage in connection with the use of the facilities and/or grounds. Property damage is to be reported immediately.  I accept responsibility for control of the reserved area until the activity is completed.  I accept responsibility for complying with all Americans with Disabilities Act (ADA) requirements.  I recognize that it is my responsibility to supply ADA required assistance for this event. I have received a copy of, read, and agree to comply with the requirements for use of the Mount Vernon District Governmental Center and any special conditions noted below.  I understand that I may have to reapply if any changes are made to this application.

Reservations are NOT confirmed until you receive a confirmation that your application has been approved.

Yes, I have read, and agree to the above statement, and the  Community Room Policy

E-mail address: