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FLUVANNA COUNTY DEPARTMENT OF PARKS & RECREATION
P.O. Box 70, Palmyra, VA 22963
434-589-2016
CANOE RENTAL FORM
Applicant Name:
Organization Name:
(Must be over 21 years of age and must be present during the event)
Address:
(Street Address)
Phone (Day):
Email:
(City, State, Zip)
(Evening)
(Cell)
I acknowledge receipt of the items marked below. I further agree to return the said items by
the return date(s) indicated and in the condition received. If any item is lost, damaged or
destroyed while in my possession I agree to pay any and all costs associated with said item(s)
repair or replacement.
Date
Signature
Office Use Only
Rental items issued by (Employee):
Check#
Date:
Cash
$
Amount of deposit returned
Signature (person receiving deposit)
Deposit Check#
Equipment & #
Canoes
Paddle
10 (s)
6 (l)
Life Vest
21 (A)
3 (C)
Trailer
Total Amount:
Quantity
Date
Deposit Cash
Resident Fees:
• ($25 per Canoe) week day rental
• ($45 per Canoe) weekend rental
Non-Resident Fees:
• ($35 Non Resident) week day rental
• ($55 Non Resident) weekend rental
*$100 Deposit for each canoe
*BUNGEE STRAPS TO BE ISSUED ONLY WHEN
RENTING THE TRAILER.
* WEEKEND RETURN HOURS BETWEEN 1PM-3PM*
Last updated May 2015