Little Shamokin Creek Watershed Association

This form is used to reserve the pavilion at the Little Shamokin Creek Watershed Association’s, Long Center.  Please
complete the form and review the attached rules and regulations.  Submit the required fee (Check’s made payable to
LITTLE SHAMOKIN CREEK WATERSHED ASSOCIATION) along with the completed Pavilion Use Permit Application to:  

Scott Hixson
658 State Route 61
Sunbury, PA 17801

Organization Name  ____________________________________________________________________
Permit Holder Name (Person Responsible)__________________________________________________
(Permit Holder must be at least 21 years of age and be attending the event)
Address: _____________________________________________________________________________
Phone: ____________________________   Email   ___________________________________________
Date Requested ___________________________  Approximate number in your party:  ______________
Event being catered?: _______  Name of Caterer: _____________________________________________
(Provide Insurance Certificate from Caterer)
Check One  -  (   ) Pavilion Use Only - $50.00 Fee     -    (   ) Pavilion and Kitchen Use - $ 100.00 Fee

In addition to the Pavilion Use Fee and additional Security Deposit in the amount of $100.00 is required to be submitted with
application.  Submit Security Deposit with a separate check.  Returned checks for insufficient funds will be charged and
additional $50.00.  If there is any damage, the security deposit will be forfeited and any additional charges
may be assessed as determined by the Little Shamokin Creek Watershed Association.  
If there is no damage, the security deposit will be returned in full.

Signing this agreement confirms that I the renter, have read the terms of this contract, have received and read
a copy of the Rules and Regulations for Pavilion Use and agree to comply with all items.  
I also agree that all those attending my event / picnic shall abide by the rules and regulations.

Name _____________________________________________

Signature __________________________________________  Date ____________________________

QUESTIONS – Contact Dan Ramer (570) 490-8113, Bob Herman (570) 975-9365, Sue Herman (570) 716-0813,               
Ted Carodiskey (570) 850-6788, Ed Markowski (570) 286-7696.
To print application: RIGHT click anywhere in document and select PRINT