Name of Group, School, or Organization: ____________________________________________
Grade Levels and Ages of Students: ________________________________________________
Number of Students and Adults: ___________________________________________________
Contact Person’s Name: ____________________________________________
Address: _____________________________________________________________________
Phone: (Business and Cell)____________________________________________
Email: ____________________________________________________________
Date(s) and times for Using the Preserve: ____________________________________________
Activities to be Performed: _______________________________________________________
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Email application, along with a valid certificate of insurance naming the Brandwein Institute and the Brandwein-Morholt Irrevocable Trust as additional insured for the date(s) of use, or a signed and acknowledged hold-harmless agreement, with a copy of photo identification to wsbav@optonline.net. You may email a purchase order for the $100 deposit. You may also mail the application, insurance certificate or hold-harmless agreement, purchase order or check for the deposit to William D. Bavoso, Brandwein Institute, 390 Minisink Turnpike, Port Jervis, NY 12771.
Email wsbav@optonline.net with any questions.
(Use the link below to print a copy of this form.)