Rental Policies

Precise facility rental rates are available upon request. All rental rates refer to the rental of the building and do not include the cost of labor, equipment, or other costs related to the event not explicitly stated otherwise.  Current rental rates and details may be obtained by contacting the Sales & Marketing Director of the Heartland Events Center and Fonner Park at 308.382.4515 extension 221.

All prospective tenants must contact the Director of Sales & Marketing to determine the availability of dates and rental rates.  A date is not considered firm until a signed contract is in place. The Management of Fonner Park may deny the use of any or all of the facility to any individual, group, organization or event that in his or her professional judgment would result in an unfair degree of competition or if it is not in the best interest of Fonner Park or the Heartland Events Center. If another tenant should request the dates in question or a portion thereof, the tenant will be required to execute a contractual agreement with 24 hours of notification or within a time as specified by the Management. If the contract is not received, the Management will release the dates with notice.

A deposit may be required in order to secure a date and location at Fonner Park.  A non-refundable 50% deposit is due upon signing of the contract and the balance is due 30 days prior to the start of the event. Management further reserves the right to require a deposit to cover all estimated expenses.

Wedding receptions require the 50% non-refundable deposit with the balance of the rent due and payable one full week prior to the wedding reception.  Additionally, all known expenses must be paid in advance, including any alcohol expenses that are hosted by the wedding tenant.  Any residual fees are due and payable upon receipt of the invoice.  Further, a credit card must be retained on file with Fonner Park/Heartland Events Center until all payments have been received for the wedding reception.

Catering deposits and payments must adhere to the requirements set forth by the facilities’ contracted caterer(s).

The Fonner Park management reserves the right to require an additional sum in advance as a damage deposit which is refundable after the event, when a walk-through examination of the facility is completed and no damage is detected.  The tenant will be charged either at the time of settlement or within 30 days for any damages related to the event which must be immediately paid without recourse.  It is solely the responsibility of the tenant to recover such charges from the tenant’s insurance carrier.  Submission of an advance damage deposit in no way relieves the tenant of the obligation to provide a Certificate of Insurance for coverage as outlined in the Liability Insurance section of the rental agreement, nor does it limit the right of Fonner Park to charge the tenant for the full amount of damages incurred even if the amount exceeds the advance damage deposit.

Fonner Park accepts credit card payments.  A 3.5% convenience fee applies to all credit card payments.

All charges due to Fonner Park are payable on demand. Credit Card payments are acceptable forms of payment. A 3.5% convenience fee applies to credit card payments.

The lessee shall obtain, at its own cost and expense, commercial general liability insurance in the name of Licensee which shall insure all operations of Licensee. Such insurance shall be written with a limit of at least One Million Dollars ($1,000,000.00) combined single limit for bodily injury and property damage liability, personal injury liability and coverage for all acts and/or omissions of any employees, agents, players, performers, contractors or sub-contractors retained by Licensee. Lessor reserves the right to require an increased amount of insurance based on the nature of the event.  Such insurance shall be endorsed to be primary to and not contributory with any coverage of Licensor, Fonner Park, which may be applicable to the claim.

The lessee shall also maintain, at its own cost and expense, Workman’s Compensation Insurance for any and all employees, and other employees whose services are contemplated by the event.

Certificates evidencing insurance required shall be provided to Licensor not less than ten (10) days prior to the event. The policies shall also provide, and the certificate shall so note, that the coverage may not be canceled or that a major change in coverage may not be implemented without at least (30) days’ prior written notice given to Licensor.

Note: These fees, services and service requirements may vary from event to event and are applicable on a case by case basis.

Charges and Fees:

Advertising

Catering/Hospitality Services

Credit Card Fees

Facility Use Fee

Incidental Fees (furniture/linens, towels, stage props, etc.)

Insurance

License Fees (BMI/ASCAP, etc.)

Long Distance Service

Royalties

Sales Tax

Sound & Lights

Stage (rented)

Ticket Printing

Telephone Lines (in-house)

Staffing:

If the following services are required for an event, the cost of labor will be charged:

Bartenders

Box Office Labor

Dedicated Ambulance Service

Electrician

EMT Medical

Forklift Driver

House Sound / Lights Operator

Janitorial Costs

Runner Fees

Scoreboard Operator

Security

Stagehands

Technical Support

Ticket Seller & Takers

Ushers

Video Engineer

Video Production

Equipment:

If used, other Fees may apply:

AV Screens

Forklift

Furniture

Stage (facility owned)

Sound System

Spotlights

Video Scoreboard

Video Cameras

Fonner Park is available to assist event promoters with their marketing needs. Specifically, the Marketing Department can recommend print, broadcast and social media advertising outlets; can aid in writing and releasing publicity to local and regional news outlets through press releases, media advertisements and e-mail blasts; and distribution of information regarding upcoming events to the appropriate mediums.

The Fonner Park Sales & Marketing Director is Dianne Willey. Call (308) 382-4515 for more information.

Local Media:  A current list is available to rental tenants upon request.

Fonner Park has 30 acres of hard surface, lighted, free parking that can accommodate 3,200 vehicles.

Aerosols, Paint Cans, Pressurized Cans

No aerosol cans, paint cans, or pressurized cans of any sort will be allowed inside the Five Points Bank Arena under any circumstances! Anyone using them will be excused from the Arena.

Alcoholic Beverages

No alcoholic beverage may be brought onto the Fonner Park Campus by any person other than Lessor’s concessionaires.

Excessive use of alcohol will not be tolerated. No one under the age of 21 is permitted to drink alcoholic beverages.

A duly qualified law enforcement officer of federal, state, and local governments may, at no cost, enter, inspect, and search the buildings and grounds at Fonner Park without a warrant or other process to determine compliance with the provisions of federal, state, and local laws.

Alteration of Leased Premises

Demonstrations of digging, trenching, and excavation or tenting must be approved in writing by Lessor.

Lessee shall not make any alterations, improvements, additions or changes to the Leased Premises without the prior written consent of Lessor, which consent may be withheld at its sole discretion.

Americans with Disabilities Act     

The Fonner Park facilities are public facilities and are subject to Title II of the Americans with Disabilities Act (ADA). The facility is accessible to disabled patrons, as required by the ADA and applicable regulations.

The Lessor is responsible for making aisles, exhibits, displays, meetings, etc., accessible to qualified individuals with a disability attending the event with respect to setup, location of exhibits on the exhibit floor, paths of travel, and other aspects of the event within the Lessor or one of the Lessor’s exhibitors’ control.

The Lessor should include a notice in the Lessee’s event advertising, and/or publicity releases, stating that disabled patrons should notify the Lessee and Fonner Park at least one week prior to the Lessee’s event should a reasonable accommodation be needed.

Fonner Park will use its best efforts to assist the Lessee in identifying local providers of temporary auxiliary aids and services, although the Lessee will remain ultimately responsible for identifying and contracting with such providers.

If the Lessee fails to arrange for a reasonably requested temporary auxiliary aid or service, Fonner Park management shall have the right, but not the obligation, to provide or arrange for such temporary auxiliary aid or service and the Lessee must reimburse Fonner Park the cost of providing and arranging for such temporary auxiliary aid or service as determined by Fonner Park.

Animals/Pets

With the exception of service animals and animals that are a part of an exhibit or show, animals or pets are not permitted in the Fonner Park facilities.

There shall be no loose or unattended dogs/pets on the Fonner Park grounds. All dogs/pets must be on a leash or in a cage.

Do not leave animals unattended in or tied to your vehicle. For their safety, animals may be removed from the premises by animal control officers and impounded.

Auxiliary Vehicles 

No auxiliary vehicles such as golf carts, four wheelers or ATV’s will be allowed in any Fonner Park barns or buildings during an event. Exception would be for load in and load out only.   

The owner and driver of the vehicle must have a valid driver’s license. No one under the age of sixteen (16) will be allowed to drive an auxiliary vehicle while on the Fonner Park grounds. This will be strictly enforced.

Proof of insurance for the vehicle must be provided at check-in, naming the official entity/entities as additional insured.

In accordance with Nebraska motor vehicle traffic laws, the consumption of, or driving under the influence of any alcohol, narcotic drug or any illegal substance while operating an auxiliary vehicle on the Fonner Park grounds is strictly prohibited. The complete Motorized Vehicle Policy may be accessed by contacting your event planner. 

Concessions and Catering

Fonner Park shall have exclusive rights to operate and receive all receipts from any concession stands utilized in the facilities and on the surrounding property. Lessee may have the right to contact third parties from an approved list provided by Lessor, to handle additional food and banquet needs.

Pepsi Cola Corporation is the official soft drink sponsor for Fonner Park. Accordingly, Lessee acknowledges and agrees that only Pepsi® products will be allowed to be served at the Leased Premises.

No food or beverage is permitted to be brought into the Leased Premises for public or personal consumption without prior written consent from Fonner Park management. It is understood by Lessee that its vendors may not do sampling unless prior permission has been given in writing by Lessor. If Lessor grants written permission in either instance, Lessee shall be responsible for adherence to applicable State Board of Health food handling and safety regulations, and to provide the required insurance coverage no later than thirty (30) days prior to the event.

Fonner Park has exclusive rights to all alcohol activities and will provide staff as they hold the facility liquor license. All alcohol related activities shall be scheduled with Fonner Park, by calling the General Office at 308-382-4515.  Security is required and will be billed separately.

Corporate Sponsors

Lessee shall use all relevant building sponsorship logos and names, if any, in all of Lessee’s promotional advertising.

Drug-Free Workplace

No drugs or contraband of any kind are allowed on the Fonner Park property.

Electrical

Lessee, its employees, agents, and subcontractors shall not install wiring or do any electrical work on or about the Leased Premises.

Events that require additional electrical needs shall be required to utilize the services of the facilities’ contracted electrician.

Elevators

All equipment shall be transported utilizing the freight elevator (carts, pallets, etc.). Freight elevators are to be operated by Fonner Park.

Under no circumstances are public passenger elevators to be used for transporting equipment or exhibit materials.

Equipment Restrictions

Excavators, dozers, tractors or similar equipment with steel and/or metal tracks or wheels are prohibited inside the facility. Also prohibited is the use of loader buckets with teeth and/or grapple attachments. The sole exception to this policy is the display of such items within an exhibit (such as antique tractors with steel, iron, or similar metal wheels) and in those occasions, Fonner Park approval is required a minimum of 30 days prior to the show.

Facility Access

This Lease does not include access to the roof of the Leased Premises or the placement of communications equipment or any other purpose.

Guest Conduct Rules

Guests interfering with other guests’ ability to enjoy the events may be subject to removal.

Guests using foul or abusive language or inappropriate or unacceptable gestures may be removed from the Fonner Park facilities.

Guests appearing impaired may be removed from the Fonner Park facilities and may be turned over to the authorities. The house reserves the right to discontinue selling alcohol to a patron that exhibits impaired behavior.

Hazardous Materials

The Lessee its agents, contractors and employees shall not cause or permit any Hazardous Materials other than janitorial supplies in reasonable quantities which are used in accordance with manufacturer’s instructions and applicable law, to be brought upon, stored, used, generated, released into the environment, or disposed of on, in, under, or about the Leased Premises.

The term “Hazardous Materials” shall mean and include any hazardous or toxic materials, substances, or wastes including (a) any materials, substances, or wastes that are toxic, ignitable, corrosive, or reactive and that are regulated by any local governmental authority, any agency of the state of Nebraska, or any agency of the United States government, (b) petroleum and petroleum‑based products, (c) urea formaldehyde foam insulation, (d) polychlorinated biphenyls (“PCBs”), (e) freon and other chlorofluorocarbons and (f) asbestos and asbestos-containing materials.

Heat

During winter months, Lessee SHALL NOT turn off the heating system, and shall turn the heating system to no cooler than 60 degrees to avoid pipes freezing.

Insurance

Lessee shall provide and maintain in full force and effect, insurance coverage, as listed in the sublease agreement. A Certificate of Insurance must be received no later than thirty (30) days prior to the first day of move in.

Leaflets/Brochures

Distribution of any printed materials or selling of any items is prohibited on the Fonner Park grounds, including the parking lots, walkways and inside all buildings, unless permission from management has been given.

Lost and Found

Lost and found items are located in the Fonner Park General Office. Please call 308-382-4515 for more information on claiming lost and found items.

Motorized Equipment

Authorized Fonner Park personnel will operate all Fonner Park equipment. No persons may authorize the use or transportation of any equipment, furnishing, or other article which is the inventoried property of Fonner Park, for any group, organization, or party of any description or type whatever, to any place or places outside the immediate confines of the Facility.

Service contractors are required to provide all equipment needed for the handling of freight.

The Lessee or Lessee’s service contractor is required to ensure that all equipment operated in the Facility does not drip oil or any other staining solutions. Any vehicle that drips oil or staining solutions will be removed immediately from the Facility.

No one, other than designated persons of the official service contractor(s) for the Lessee’s event, are authorized to operate any motorized cart, lift equipment, etc., of such service contractor in the Facility.

Any person(s) operating motorized equipment must have a valid driver’s license.

Lessee will be charged for any and all costs incurred for cleaning and/or repairs due to damages caused by the Lessee’s staff, Lessee’s service contractors, vendors, and/or exhibitors’ equipment being operated within the Facility and on the Fonner Park grounds (including loading docks and parking lots). Lessee shall reimburse Fonner Park for any replacement costs of property that is damaged beyond repair.

Under no circumstances are motorized equipment or vehicles to be operated in any areas in the Facility or in the pedestrian area in front of the Facility, other than the exhibit halls, without written approval from Fonner Park Management.

Motorized equipment and/or vehicles which are part of a display will be allowed in the Facility. All equipment and/or vehicles should conform to the following fire and safety regulations:

The engine will not be operated when the building is occupied.

A maximum of 5 gallons of fuel per vehicle or piece of motorized equipment when entering the building.

The fuel fill cap is secured with a lock-type or securely taped with a material that is non-petroleum soluble.

The battery cables are disconnected from the battery and the battery terminal will be securely covered.

The motorized equipment and/or vehicle will be securely locked when unattended.

An approved fire extinguisher will be located in the immediate vicinity.

The Fire Marshal’s Office may inspect motorized equipment and/or vehicles prior to the building being opened to the general public.

Motorized equipment and/or Vehicles displayed at Fonner Park must have a protective barrier under the vehicle (plastic or something similar), including beneath the tires.

All required precautionary measures, permits, and related fees are the responsibility of the Licensee to obtain by working with their Fonner Park Event Coordinator.

Personal golf carts, segways, skateboards, scooters, hoverboards and drones are not permitted in the Fonner Park buildings and controlled parking lots, unless approved in writing by Fonner Park management.

Parking motorized equipment or vehicles in the pedestrian area in front of the Facility is prohibited unless approved by Fonner Park management.

Non-Discrimination

Lessor, for itself and its agents and employees, represents and warrants that it shall not discriminate against any lessee, exhibitor, guest, employee or applicant for employment, with respect to hire, tenure, terms, conditions, or privileges of employment or any matter directly or indirectly related to employment, because of race, age, color, religion, sex, disability, national origin, or ancestry. Acceptance signifies compliance with applicable federal and state laws, regulations, and executive orders prohibiting discrimination in the provision of services or access based on race, color, national origin, age, sex, disability, or status as a veteran.

Occupancy Rate

Occupancy rate must be in compliance with the established rating set by the State Fire Marshal’s office and as posted by facility.

Parking Lot Guidelines

Parking is on a first-come, first-serve basis in designated lots.

Tailgating is not permitted in all Fonner Park controlled parking lots.

Holding or saving parking spaces is not permitted.

Drive lanes in the parking lots must be kept clear at all times.

Parking is not permitted where posted for staff parking. Violators will be towed.

ADA parking is available in all Fonner Park controlled parking lots.

Staking of tents is NOT permitted in the parking lots or lawn areas. Tents may be anchored with weights.

Consumption of alcohol or open containers of alcohol is prohibited.

Commercial advertising banners or signs are prohibited.

Distribution of promotional items or other forms of solicitation is not permitted.

Any equipment (chairs, tents, etc.) left overnight will be confiscated or disposed of.

Fonner Park reserves the right to revoke any parking of those who do not comply with any parking guidelines.

Fonner Park assumes no obligation and no liability for any theft or damage that may occur to a vehicle or its contents using Fonner Park parking lots.

Permits – Compliance with Laws and Regulations          

Lessee shall, at its sole cost and expense, obtain all permits and licenses necessary to legally hold the Event, and shall provide copies of same to Lessor no less than thirty days (30) prior to the Event. Lessee shall comply with all applicable federal, state or local statutes, ordinances, laws, rules, and regulations, including but not limited to those relating to occupancy, sanitary and health requirements, fire and safety codes, and payment of royalties on copyrighted music utilized by Lessee in connection with the Event.

Pyrotechnics

No pyrotechnics shall be used unless a proper permit is obtained from the Grand Island Fire Department, and written authorization from Fonner Park management is obtained. The Lessee may incur an additional cleaning charge.

Publicity, Signs & Banners

Tape, stickers, nails, tacks, staples, hooks, screws, permanent markings (such as paint and

ink), and other objects, shall not be inserted or placed on or into facility walls, doors, floors, ceilings, trees or posts.

No gummed or adhesive-backed labels, stickers or signs of any kind are allowed on the Leased Premises. Athletic mat tape that leaves no sticky residue shall be used on facility floors.

Water soluble chalk shall be used in parking lots and in grassy areas.

No helium and/or mylar balloons are allowed. Lessee will be responsible for any and all damage to the facility, including that which results from balloons which end up in the heating, utility systems or high voltage powerlines.

Tabletop décor, including candles, must be enclosed in glass or metal containers, three inches above the flame. Hay bales must be sprayed with fire retardant prior to the building being opened to the public.

Security

Lessee shall, at its sole expense, provide ticket takers, doormen and other personnel, as may be deemed necessary, to regulate entrance to the Leased Premises during the Event.

Lessee shall provide adequate security during the Event. Lessor has an agreement with a Security contractor, Double Locked Security. As a condition of the lease agreement, Lessee shall employ Lessor’s Security contractor in order to provide adequate security during the Event. The Security contractor will be responsible to lock and secure all doors, windows, and entrances to the Leased Premises and to take any other reasonable security measures to protect persons and property upon the Leased Premises during the Event.  Lessee shall provide Lessor with all pertinent information relating to its needs for security and crowd control. Lessor and Lessee shall mutually agree upon provisions needed for the Event. In the event Lessor and Lessee cannot mutually agree upon the plan, Lessor retains the right to terminate this Lease or require Lessee to cancel the Event at the Leased Premises if, in Lessor’s sole judgment, Lessee’s plan for security is inadequate to protect the safety the facility and of those attending the Event.

Smoking/Vaping

Smoking and vaping are prohibited in all Fonner Park barns and buildings. Any person who refuses to comply with this policy shall be subject to ejection from the facilities.

Weapons

Weapons of any kind are prohibited in all Fonner Park facilities.

LESSEE WILL BE CHARGED FOR ANY DAMAGE, OR COST INCURRED BY LESSOR AS A RESULT OF LESSEE’S FAILURE TO COMPLY WITH THE FOREGOING TERMS AND CONDITIONS.

In the event Lessee should experience any problems or emergencies while Lessee is occupying the Leased Premises with regard to general maintenance, plumbing, electrical, or janitorial, etc., Lessee is to contact the Event Planner or the Fonner Park General Office at 308-382-4515. Night security is provided and can be reached by calling 308-380-4895. The security guard on duty will then promptly call the proper person to assist Lessee with any problems.

Effective 4/14/2021

Fonner Park / Heartland Event Center

Motorized Vehicle Rules & Regulations Agreement

Auxiliary vehicles, including but not limited to, golf carts, service carts, utility vehicles, Cushmans, and other fourwheeled vehicles (individually an “AV,” collectively, “AVs”) are included within the scope of this Motorized Vehicle Rules & Regulations Agreement (this “Agreement”). All AVs used in connection with activities and events at the Fonner Park Campus are required to have a Fonner Park issued operation permit while on the Fonner Park grounds, parking lots, and campground. Permits are required during move-in, event period, and move-out. Permits are only issued for AVs that serve to advance the operation of the event in process or that provide a service to Fonner Park vendors, exhibitors, administration staff, etc. Permits are issued at the Fonner Park General Office. Permits are issued at the discretion of Fonner Park and Double Locked Security.

SAFETY POLICY:

“It is the intent of this company to provide a safe workplace for everyone. Accident and injury prevention is an important part of our job. Working together, we can achieve our safety goals. Safe working practices are important. Safety is everyone’s responsibility. It is the policy of this company to protect our employees, patrons, equipment, facilities, and grounds. Employees and vendors operating AVs must be authorized to drive the vehicle, and constantly be aware of others when driving on the Fonner Park grounds.”

By signing below, the undersigned permit owner agrees to the following:

1. AVs without a permit will not be allowed on Fonner Park grounds at any time.

2. High-powered motorized sports vehicles are not permitted. This Agreement authorizes the undersigned to operate only the AV identified at top of this Agreement. Privately owned AVs are subject to inspection and approval of Fonner Park or Double Locked Security prior to use on the Fonner Park grounds.

3. All AV drivers must be a minimum of 16 years of age and have a valid driver’s license issued by the applicable state agency. An identification card is not considered a valid form of I.D. A copy of the driver’s license must be on file with this signed Agreement. Any and all unauthorized or unapproved drivers will be the sole liability of the AV owner(s).

4. AVs are not permitted on city streets. However, all drivers of AVs shall observe all Nebraska motor vehicle traffic laws while driving an AV (e.g. stopping at stop signs, yielding to pedestrians, refraining from using cell phones or texting while driving). AVs may only be driven between dawn and dusk if equipped with headlights and brake lights in operating condition. AV drivers will yield to pedestrians and animals, and use safe speeds at ALL times, especially in areas of high traffic. An AV should be operated at a speed equivalent to a well-paced walk, but no faster than 15 mph.

5. AVs are not permitted inside any Fonner Park buildings or barns, at any time.

6. In accordance with Nebraska motor vehicle traffic laws, the consumption of, or driving under the influence of any alcohol, narcotic drug or any illegal substance while operating an AV on Fonner Park grounds is illegal. Any violations will result in the automatic revocation of your AV permit.

7. The number of passengers and load capacity of an AV shall not exceed the manufacturer’s rated limit and all passengers must be transported in accordance with the manufacturer’s recommendations. Passengers must be seated while operating the AV. Infants and children are not allowed on the driver’s lap and are not allowed to steer the AV. Passengers are not allowed to ride in the box of the AV.

Permit #: ____________________________________ Wristband

Type of AV: ___________________________________________________________

Ticket #: _____________________________________________________________

ATTACHMENT A

Effective 4/14/2021

8. AV keys are not to be left in unattended AVs. Drivers must keep their AV keys with them at all times.

9. In the event any term of this Agreement is violated, Fonner Park may do any one or more of the following:

-Fonner Park and Double Locked Security each have the authority to revoke an AV permit at their sole discretion.

-Fonner Park and Double Locked Security each have the authority to impound any AVs issued by the Fonner Park

and Double Locked Security, at their sole discretion.

-Fonner Park and Double Locked Security each have the authority to require any privately owned AVs to be removed from the Fonner Park grounds, at their sole discretion.

-A first time violator of any of the terms of this Agreement may receive a warning if the circumstances warrant, at

the sole discretion of Fonner Park and Double Locked Security . In such event, a second violation will result in the

automatic and immediate revocation of the driver’s AV permit and the AV will be impounded, if such AV was issued by Fonner Park and Double Locked Security. Privately owned AVs will be required to be removed from the Fonner Park grounds.

-Reckless driving, negligent driving or any other driving that may impair or be harmful to the safety of visitors, participants, vendors, exhibitors, or others present at Fonner Park (each of the foregoing as determined by Fonner Park and Double Locked Security in their sole discretion), shall result in the automatic revocation of a driver’s AV permit and the AV will be impounded, if such AV was issued by the Fonner Park and Double Locked Security . Privately owned AVs will be required to be removed from the Fonner Park grounds.

-Permits are issued at the discretion of Fonner Park and Double Locked Security. Fonner Park and Double Locked Security reserve the right to revoke permits and remove AVs from Fonner Park grounds, at any time and for any reason.

Vendor/Attendee/Company: I hereby certify that I have read and agree to the above Fonner Park Motorized Vehicle

Rules & Regulations and have provided a copy of all relevant valid driver’s license(s).

___________________________________________________________________ __________________

Signature Date

________________________________________ ________ ______________________________________

Printed Name Birth Date Phone Number

_________________________________________________________________________________________________

Address (Street, City, ZIP)

ADDITIONAL DRIVERS: I hereby certify that I am responsible for the following drivers and that they each meet aforementioned rules and requirements applicable to myself and that I will be held responsible for their actions.

______________________________ ___________ ; ________________________________ ___________

Printed Name Birth Date Printed Name Birth Date

______________________________ ___________ ; ________________________________ _________

Printed Name Birth Date Printed Name Birth Date

______________________________ ___________ ; ________________________________ _________

Printed Name Birth Date Printed Name Birth Date

______________________________ ___________ ; ________________________________ _________

Printed Name Birth Date Printed Name Birth Date

______________________________ ___________ ; ________________________________ _________

Printed Name Birth Date Printed Name Birth Date