House Use Request Form

Request for Use of NIA Property

All requests for permission to use any NIA properties or facilities must be made through the NIA

House Use Chairperson, and are subject to approval by the NIA Executive Board. The House

Use Chairperson’s contact information is as follows:

Anna-Karin Kuliga, NIA House Use Chairperson 203-375-3611

1773 Huntington Turnpike, Trumbull, CT 06611

You must be an NIA member in good standing to request the use of any NIA properties or

facilities. Additionally, all persons granted the use of any NIA properties or facilities agree to

the following conditions:

a) That they assume liability for any damage or destruction to NIA properties or facilities

resulting from their use of said properties or facilities for their event/activity;

b) That they assume liability for any personal injury to any person(s) resulting from their

use of said properties or facilities for their event/activity;

c) That they agree to pay the “house use fee” of $75, payable prior to the date of the event,

and delivered to the House Use Chairperson; (non-members $125).

d) That they agree to abide by all applicable NIA rules & regulations regarding the use of

NIA properties or facilities (posted on the NIA website);

e) That, should they fail to comply with any of these conditions, they may be denied the use

of any NIA properties or facilities, and may be subject to additional recourse, including

any necessary legal options, by the NIA and/or their representatives.

House Use Inquiry Form

Please complete and submit the form. After receiving confirmation of reservation from the House Chair, submit payment in the amount of $75 for “house use fee” (made payable to the N.I.A.) and return to NIA House Use Chairperson at the above address. Payments can also be submitted online here. SUBMIT PAYMENT

Name of NIA Member::
Address::
Phone Number(s):
E-mail Address::
Event Beginning Date/Time Requested: *
Event Ending Date/Time: *
Location Desired:	Starkweather House NIA Ballfields NIA Picnic Area Frog Pond Other (Specify in Comments)
Purpose of Event/Activity:
Notes/Comments/Requests::
Insurance Carrier & Policy #:
The undersigned acknowledges that they have read, understand, and accept all conditions associated with the use of NIA properties or facilities.:
Security Code: *