Organization Name: __________________________________________
Contact Person: __________________________________________
Street Address: __________________________________________
Mailing City/State: ______________________________ZIP_________
Telephone Number: (Home)_________________(Work)_____________
When is best time to reach contact person? _____________________
Special Event (Title):__________________________________________
Brief Description: __________________________________________
__________________________________________
__________________________________________
__________________________________________
DATE of EVENT: ____________________________
Program begins at: ____________________________
Program ends at: ____________________________
Location: __________________________________________
__________________________________________
Will the event be: Indoor? ________ Outdoor? ________
Will the program be aired live? ______ Yes ______ No
______ Taped and Live Show
Are 120 Volt 60 Hz power outlets accessible and in area will program will be held? ______ Yes ______ No
The above-named organization/individual has read and accepts the "Guidelines for Taping/Airing Public Events for Public Access by the Muskego Public Access Group (Cable Club)" as received with this application form. The above-named organization/individual agrees to indemnify and hold harmless the MPAG and the City of Muskego from any and all liability which might be occasioned to said MPAG and City by virtue of agreeing to volunteer to tape/air the above-mentioned special event.
Date:______________________________ ___________________________
Applicant's Signature
___________________________
Title (Position)
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Office Use:
Date Department Received: __________________ ___________________
Recreation Director
Program accepted for taping/airing?: ______ Yes ______ No
Operator(s): __________________________ ________________________
Please remit application to: Muskego Parks & Recreation Dept.
Muskego Public Access Group
P.O. Box 903
W182 S8200 Racine Ave.
Muskego, WI 53150