Private Nature Program Request Form

Important information:
This is a program request form. Park staff will contact you to schedule and confirm your request. 

Organization Account Information:
Legal Name:
DBA:
Address:
City:
State:	Zip Code:
Phone:
Fax:
What type of organization are you?
Government AgencyNon Profit Scout GroupSchool Group Public AgencyOther

Group Main Contact Information:
Name:
Job Title:
Phone:
Fax:
Email:
What is the contact's gender? MaleFemale
Is contact at least 18 years of age? YesNo
Are you an authorized representative? YesNo
Like to receive general park info via email?  YesNo
How did you hear about Dakota County Parks?

Additional Authorized Representatives:
Name:
Job Title:
Email:
Name:
Job Title:
Email:

Tax Exempt Information:
Is your organization Minn tax exempt? YesNo
If Yes, please fax your Certicate of Exemption to 952-891-7031 Attention Parks Financial.
Tax Exempt Number:
Name applied under:
Non-Profit 501 c(3)?  YesNo

Billing Information:
Contact Name:
Address:
City:
State:	Zip Code:
Phone:
Fax:
Email:
Billing contact's gender? MaleFemale

Activity/Group Leader Information:
Name:
Phone:
Email:
Preferred method of correspondance: EmailPhone

Activity Preferences:
1st Date:		Time:
2nd Date:		Time:
Location:	Lebanon Hills Regional Park Miesville Ravine Regional Park Spring Lake Park Reserve Thompson County Park
Activity Topic:

Group Attending Description:
Type of group:	Scouts Home School Birthday School Group Other
Age range:
Number of students:
Does your group have special needs? YesNo
If yes, please describe: