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2. Delaney's Safety House
4. 
8. Requestor Contact Information
10. First Name*
11. Last Name*
13. Contact Email*
14. Contact Phone*
16. Agency You Represent*
    -- Select One --Central Orchard Mesa Fire DepartmentClifton Fire DepartmentDebeque Fire DepartmentEast Orchard Mesa Fire DepartmentGateway Fire DepartmentGlade Park Fire DepartmentGrand Junction Fire DepartmentLands End Fire DepartmentLower Valley Fire DepartmentPalisade Fire DepartmentPlateau Valley Fire DepartmentMesa County Sheriff's OfficeOther
17. Other- type the name of your organization below*
19. Dedicated Staff for Event

    For safety reasons, this resource requires a minimum of four dedicated staff members. List the names of your four dedicated members below. 

29. Event Details

31. Delaney's Safety House must be set up on a large grassy area in order to be staked down, and must have access to power within 50 feet of the proposed event site. By completing this section, you acknowledge that the chosen site meets these requirements. 

33. Event Name*
34. Event Address and location description*
36. Pick up Date*
    Pick up Date

    Pick up Date

    Pick up must be at least 24 hours prior to event

37. Event Date(s)*
    Event Date(s) Start Date

    Event Date(s) Start Time

    —

    Event Date(s) End Date

    Event Date(s) End Time
38. Return Date
    Return Date

    Return Date

    Return date must be at least 24 hours after event

42. Conditions and Release of Liability

    Required for Fire Agencies utilizing the Safety House.

44. Agreement to Follow Safety Guidelines*

    Our agency agrees to abide by all safety and cleaning recommendations associated with the Safety House including:

    • Minimum of three person staffing for the duration of the use of the house
    • All people using the safety house will be under adult supervision at all times
    • Youth must crawl on hands and knees transitioning from the house to the slide area
    • Participants will not engage in running, jumping, or bouncing off walls inside the house
    • The Safety House will not be utilized if winds exceed 10 mph or if lightning or thunder are present
    • The Safety House will be set up either indoors or on grass and appropriately staked down
    • If being used outdoors a tarp will be placed under the front of the house and throughout the interior of the house to prevent soiling
    • No shoes will be allowed inside the house
    • The house will be wiped clean before retuning 
    • The house will be inspected for damages before returning, all damages or malfunctioning equipment will be reported upon return
    • If the checkout form is found to be incomplete or false upon next use the Agency may be barred from future use of the resource
45. Release of Liability*

    Our Agency acknowledges there is inherent risk in transporting, setting up, and using the Safety House both for facilitators and the public. The requesting Agency acknowledges that the liability associated with the transportation and use associated with the Safety House is the sole responsibility of the requesting Agency. Furthermore, by signing the Agency acknowledges that it carries the appropriate insurance and liability coverage for all participants and equipment. 

    
    

    • The requesting agency is voluntarily participating in the use of the Safety House. The agency understands that there are risks associated with participation in this Activity, such as physical and/or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability, death or economic loss. These injuries or outcomes may arise from the Agency's or other’s actions, inactions, or negligence, or the condition of the Activity location (s) or facility (ies). Nonetheless, the Agency assumes all risks of participation in this Activity, whether known or unknown to Agency, including travel to and from the Activity or any events incidental to this Activity.
    • The Agency agrees to hold the Mesa County Fire Chiefs, the City of Grand Junction, and Grand Junction Fire Department harmless from any and all claims, loss or damage to my personal property, liabilities and costs, including attorney’s fees, as a result of my participation in this Activity, including travel to and from the Activity or any events incidental to this Activity. If the Mesa County Fire Chiefs, the City of Grand Junction, and/or Grand Junction Fire Department  incurs any of these types of expenses, I agree to reimburse the Mesa County Fire Chiefs, the City of Grand Junction, and/or Grand Junction Fire Department.
    • The requesting Agency has read this document, and on behalf of the requesting Agency I am signing it freely. I understand the legal consequences of signing this document, including (a) releasing the Mesa County Fire Chiefs, the City of Grand Junction, and/or Grand Junction Fire Department  from all liability, (b) waiving my right to sue the Mesa County Fire Chiefs, the City of Grand Junction, and/or Grand Junction Fire Department , (c) and assuming all risks of participating in this Activity, including travel to and from the Activity or any events incidental to this Activity.
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47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

* indicates a required field