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APPLICATION FOR THE USE OF POTOMAC STORM GYM


64 Dupont Rd., Martinsburg, West Virginia

EMAIL [email protected]


 PLEASE ANSWER ALL APPLICABLE QUESTIONS


1. __________________________________________________________________________________
(Name of Individual or Organization)


2. __________________________________________________________________________________
(Property requested, specify entire gymnasium, single volleyball court, and/or any equipment)


3. Dates & Times Of Usage:

Start Date: ________________ End Date: ____________________

Time Use Begins: ____________________ Time Use Ends: _____________________

Day(s) of Week Usage: _________________________________________________________


4. Specific purpose for use of property: ___________________________________________________
___________________________________________________________________________________
(i.e., Sports Lessons, Sports Practice, Sports Tournament, Open Gym, Tryouts, Other — please be specific)

Will admission be charged: Yes _____ No _____

Will anything be sold: Yes _____ No _____

If the gym will be used for sports lessons, practices, or scrimmages, specify the number of and names of ALL persons who will be using the facility. Specify (for each person) if they are current Potomac Storm VBC coaches, players, and/or parents. You may attach a copy of team rosters, for scrimmages.

Number of persons who will be using the facility: _________

Names of persons who will be using the facility ( Non-PSVBC members MUST submit a signed/dated Liability Waiver )
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________


5. Names, addresses & phone numbers of persons responsible for this event (two names, please fill out completely):
Name: _________________________________    Name: _____________________________________
Address: ___________________________________            Address: _________________________________      _______________________________                   ____________________________________
Telephone: ______________ Telephone: ______________


6. Person who will open/close facility (MUST be present the entire time that the facility is in use by their group):
Name: ________________________________________________ Phone # __________________


7. Do you understand that NO property of Potomac Storm Volleyball Club should be removed from the gym and you pre-authorize charges for any missing or damaged property? Yes _____ No _____

Signature :_______________________________________________________ Date: ____________


8. A current Certificate of Liability Insurance is required, for tournaments & tryouts, before Potomac Storm VBC will approve. Have you attached a current certificate of liability insurance: Yes _____ No ____

Gym Court Rental Fees Do NOT Include Coaches Fees

( FOR PRACTICES, LESSONS, PICKUP GAMES, SCRIMMAGES )


ONE COURT - $25.00 + $5.00 PER PERSON
 / PER HOUR - CAPPED AT $40 PER HOUR
TWO COURTS - $50.00 + $5.00 PER PERSON / PER HOUR - CAPPED AT $80 PER HOUR


( COURT RENTAL FOR TOURNAMENTS, TRYOUTS, OR NON-PSVBC PRACTICES )

$30 PER HOUR ( 4 HOUR MINIMUM ) PER COURT

*** USE OF VOLLEYBALLS AND CARTS IS NOT INCLUDED WHEN GYM IS RENTED FOR TOURNAMENTS, TRYOUTS, OR NON-PSVBC PRACTICES ***


9. An AUTHORIZATION TO USE PSVBC GYM will be emailed from Panhandle Youth Volleyball Assoc. Inc. dba Potomac Storm Volleyball - An IRS determined 501(c)3 Corporation, IF your request is approved. ALL gym rental payments must be made to Potomac Storm VBC, in advance. NO gym rental payments should be made to coaches.
***Coaches fees are NOT included in gym rental fees***

Upon approval, and prior to use, payment MUST be made to Potomac Storm Volleyball Club through the VENMO App.


ALL ORGANIZATIONS REQUESTING USE MUST INCLUDE THE "AGREEMENT FOR INDEMNITY" BELOW

AGREEMENT OF INDEMNITY FOR USERS OF POTOMAC STORM GYM (64 DUPONT RD. MARTINSBURG, WV)

The undersigned, in consideration of being granted permission to use the Potomac Storm Gym facilities 
and property, located at 64 Dupont Rd., Martinsburg, WV, agrees that the undersigned and the organization that they represent, including it's officers, owners, agents, assigns, and members, shall indemnify and hold forever harmless the Panhandle Youth Volleyball Association Incorporated dba Potomac Storm VBC, its officers, agents, assigns, members, and the facility property owners, and their officers, agents, employees, and assigns, against any liability of any accident, injury, or other mishap that may occur to anyone during, or as a result of use of those facilities and property. The undersigned further agrees to defend against any claim brought against the Panhandle Youth Volleyball Association Incorporated dba Potomac Storm VBC, and/or its officers, agents, assigns, and the property owners and/or any of its officers, agents, employees, and assigns, as a result of any such accident, injury or mishap. Undersigned further covenants and agrees that it shall be covered by an appropriate liability insurance policy in the amount of no less than $1,000,000.00, for the purpose of insuring against any injury as a result of any accident or mishap during or as a result of the use of said facilities and property.

I, the undersigned, attest that I am lawfully authorized to represent the individuals or sports organization that I am 
requesting use of the Potomac Storm Gym on behalf of, that WE have read this AGREEMENT OF INDEMNITY FOR USERS OF POTOMAC STORM GYM, fully understand it's terms, understand that individuals and/or organizations making use of the gym give up substantial rights by signing it, that I/we have had opportunity to have it reviewed by an attorney, and sign it freely and voluntarily without any inducement.

PRINT NAME OF PERSON REQUESTING USE: __________________________________________________________________

ADDRESS OF PERSON REQUESTING USE: _____________________________________________________________________

SIGNATURE OF PERSON REQUESTING USE: ____________________________________________

DATE:___________________________________


============================================================================================


BEFORE ANY USE OF THE POTOMAC STORM GYM, ALL PERSONS ENTERING THE GYM MUST READ, SIGN, AND DATE THE RELEASE BELOW & SUBMIT IT TO POTOMAC STORM VBC 

RELEASE OF LIABILITY FOR USE OF FACILITY AND/OR EQUIPMENT

READ BEFORE SIGNING

 

IN CONSIDERATION OF my child/ward/myself being allowed to participate in any way, in ANY event and/or activity held on any leased or owned premises of Panhandle Youth Volleyball Association, Incorporated dba Potomac Storm Volleyball Club; its directors, officers, officials, agents, employees, volunteers, other participants, sponsoring agencies, sponsors, advertisers, and owners and lessors of premises, (hereinafter individually and collectively known as the CLUB), whether such activity is at the Club's 64 Dupont Road, Martinsburg WV facility or at any other facility utilized by the Club, the undersigned acknowledges, understands, and agrees that:

The risks of injury and illness (including communicable diseases such as MRSA, influenza, and COVID-19) to my child/myself/and others from the activities involved in these programs are significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce these risks, the risks of serious injury and illness do exist; and,

  1. FOR MYSELF, MY SPOUSE, AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE CLUB, or others, and assume full responsibility for my child’s use of the Club's facility(s) and equipment; and,

  2. I willingly agree to comply with the Club’s stated and customary terms and conditions for participation. If I observe any concern, I will remove my child from the participation and the Club's facility immediately; and,

  3. I myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS the Club, WITH RESPECT TO ANY AND ALL INJURY, ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, incidental to my child’s involvement or participation in these programs and/or use of the Club's facility(s) and/or equipment, WHETHER ARISING FROM THE NEGLIGENCE OF THE CLUB OR OTHERWISE, to the fullest extent permitted by law.

  4. I, for myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS the CLUB from any and all liabilities incidental to our involvement or participation in these programs and/or use of the Club's facility(s) and/or equipment, EVEN IF ARISING FROM CLUB'S NEGLIGENCE, to the fullest extent permitted by law.

  5. I, the parent/guardian, assert that I have explained to my child/ward: the risks of the activity, his/her responsibilities for adhering to the rules and regulations, and that my child/ward understands this agreement.

I, FOR MYSELF, MY SPOUSE, AND CHILD/WARD, HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND IT'S TERMS, UNDERSTAND THAT WE HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Print Name of Participant: _______________________________________

Print Name of Parent/Guardian (If Participant is UNDER 18 years of age): _______________________________

Signature of Parent/Guardian/Participant (If Participant is 18 years of age): __________________________________

Date Signed:___________________________________ 

Name of Child/Ward: ___________________________________

Signature of Child/Ward: __________________________________

Date Signed:___________________________________

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Potomac Storm Volleyball Club

64 DUPONT RD 
MARTINSBURG, West Virginia 25404

Email Us: [email protected]
Phone : 304-839-5106
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