HomeMy WebLinkAboutMINUTES - 06032003 - C.148 BOARD OF SUPERVISORS CONTRA COSTA
COUNTY
FROM: William Walker, M.D.
Health Services Director
TO
DATE: April 30,2003
SUBJECT: Use of Pacheco Community Center for a Health Services
sponsored event
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
Recommendation:
AUTHORIZE the Health Services Director or his designee, Wendel Brunner, M.D., to sign a hold
harmless agreement indemnifying Pacheco Community Center located at 5800 Pacheco Blvd, Pacheco
on June 6, 2003.
Background:
The facility will be used on June 6, 2003 for the Family, Maternal & Child Health Programs to hold a
Roundtable forum for perinatal staff.
Fiscal Impact:
Funding for rental is included in the State allocation for Maternal & Child Health Programs
CONTINUED ON ATTACHMENT: 3 YES O NO SIGNATURE
RECOMMENDATION OF COUNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
APPROVE OTHER.
SIGNATURE S`c ' P
T.5 i. .� M f._F""Y
ACTION OF BOARD�&1 "� " ft v �` i t ,'> APPROVED AS RECOMMENDED OTHER
�y
VOTE OF SUPERVISORS
UNANIMOUS (ABSENT ,/ 1r ' :> - } I HEREBY CERTIFY THAT THIS IS A TRUE AND
CORRECT COPY OF AN ACTION TAKEN AND
AYES: NOES: ENTERED ON THE MINUTES OF THE BOARD OF
ABSENT: ABSTAIN: SUPERVISORS ON THE DATE.SHOWN.
—7-
ATTESTED
CONTACT PERSON: Itika Greene(313-6253) JOHN SWEE CLERK OF THE BOARD OF
SUPERVISORS AND COUNTY ADMINISTRATOR
CC: Public Health Director
Health Services Director
FMCH may:
BY s # s s vt ti DEPUTY
PACHECO TOWN COUNCIL COMMUNITY CENTER APPUCATLON/r.C?NTRAc7 FOR tlSE
MW PACHECO BLVD.,PACHECO,CA W53
Ph.: *125-176-W" FAX: 925-47S-77A2
DATE. P Qy y . -j-z
RECEIPT o-(DEPOSIT Mathod of Payer • No Cash Accepted
DATE:
{ RECEIPT#.(RENT) Method of PayrnerA—No Cash A=ePted
G,r�x�y�C1,a'�+►xc.a�cx� ►'s�Ca4��lC�, y �.'bk+�te*•Cabt�a►��.1R..1.�1'1 �#"�`0.• �tk,�t'OU1 .___
1lwiDlYID #2GANt2ATION NAME .'aa rt'vtc-a PERSON IN CHARGE OF ACTIVITY
STREET STREET
CITY �Z -- I ZIP CITY ct , r , ZIP
PHONE-I)AY P"ONE-EVE. PHOW-DAY I E-.VE
f f f M#i i f M M M f f M#M f f M f f i i f i i i■f#M f f i f#f{t i i#■i M M M#f i f M i iF i f M a###f i i#i f f f M f f f f M 7f i f M f f f f M f y M##
DATE OF ACTIVITY: -Skl .-D TYPE OF ACTIVITY: CPA� a aF GUESTS: LO-IC)
ENTRY TIME: �.t 0 0 G N-^ DEPARTURE TIME: TOTAL HOURS: ._
R+t#�fskA#M+sae,et�r4#+iirstirMi4kryR.Ita4:R##Niww:ikkk##+.RrkRkiRM#rRR:Ai kRirsfe#Rr►s+ptMkk kAirtkkkNAtRMfalJdi 14#kt�4ARN#ukkktiraRkiid7lf.[x�#*lt+tsesAkRR=ttilrly#nR
FACiLETY REi�E1lra3T
AudEtorlurri: It r_ "I� ; Deposit to how date&for dernages -a .0
Security(kord Fee 41 14 tj tAkohollcrowd control)
Conference Room 3_., Cleaning S C�
Sub-Total t Set up 0%W owvN.
Pachrrco Raja.Discount f_�_ Take clown x
Seib-Total S_��}s C�y Total nt #
�i{i .Elett=NT
Your signature Indicates thot you: Have mead the Rules and Regulations of the EACHECO TOWN Cr3I1NCII_
regarding use of the Pacheco Community Center. Will take full responsibility to Ina re that the use of these
facilities by the organization/group you represent Is In full compliance with said rules. Will hold the Pacheco Tes+afirn
Council&Contra Goons County hsrml+ s foar any damage claim of any kind resulting from misuse or violation of
the rules and agree to accept responsibility for any such claims. Acknowledge that you will not misrepresent any
Item regarding the type of activity, a of people to attend,etc. o especially the cress of alcohol. Acknowledge
resPonslblllty for supervision of t wa behavior of all qua cts, and agree to be responsible for the activltles and
supervision of any minor$. Acknowledge possible full or partial forfeiture of your security/damage deposit due to
violation of this agreement and accept the refund amount determined to be appropriate by the Pacheco Town
CouncUl Community Center Owe.Irning Board. Such refund Is dotemirsed on severity of violation of rules. You
should also be aware that last minute cancellation or a"no show" without notification may result in full or partial
forfeiture of your deposit:
Appllcm—w—S signature Date
(APPLICATION TAKEN BY) Approved Denled Payment ,copy of contract received by supervisor
Lker><re Permit No.MEOUIRED FOR SALE OF ALCCItiOQ
Deposit Received Keele&Amount) Balance Remaining Balance Due by Gat4d$Received
.max d m Si l t' T ' "'aim cIF + pus ,r:
Original deposit 'Charg#s against deposit Amount Refunded Dane check a
fif#ME t7F Eii#<NT t�sra=ra f�- j���,,•` t l � ` 2-/,-6
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