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Athletic Field / Facilities Request Form

2. A separate form must be submitted for each sport/activity with a detailed list of locations, dates, and times.

   A separate form must be submitted for each sport/activity with a detailed list of locations, dates, and times.

4. Applicant First Name*

5. Applicant Last Name*

7. Email Address*

9. Address*

11. City*

12. State*

13. Zip*

17. League/Organization Name*

19. Sport/Activity*

21. Type of Event*

    Check all that apply.

    1. Practice
    2. Game
    3. Tournament or Other
23. Requested Field

25. 1st Choice*

27. 2nd Choice

29. 3rd Choice

31. Other Information

35. Date & Time

36. User Name & Age

38. Date & Time

39. User Name & Age

41. Date & Time

42. User Name & Age

44. Date & Time

45. User Name & Age

47. Date & Time

48. User Name & Age

50. Additional Users

54. Insurance Policy*

    Please attach a copy of your insurance policy listing Powhatan County as additionally insured.

55. Team Roster*

    Please attach a copy of your team's roster with current addresses for team field use other than tournaments or camps.

59. Application Approved

    1. Yes
    2. No

61. Date
    Date

62. Fee (If Applicable)

64. Recreation Coordinator

Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field