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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.
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