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2. Event Information

   This indemnification and hold harmless agreement should be filled out and signed for all events that are NOT providing a required insurance certificate. Insurance certificates must name the City of Cocoa as an additional insured.

4. First Name*
5. Last Name*
7. Event Date*
   Event Date
9. Event Facility*

   1. Cocoa Civic Center Ballroom
   2. Cocoa Civic Center Conference Room
   3. Porcher House
   4. Myrt Tharpe Square Gazebo
   5. Heart of Cocoa Community Meeting Room

   1. Riverfront Park
   2. Riverfront Park Pavilion
   3. Lee Wenner Park
   4. All aforementioned facilities
11. Indemnification and Hold Harmless*

    1. I agree to the following:

    The undersigned has elected not to provide additional liability insurance coverage, that would afford additional liability protection to the City of Cocoa and its officers, employees, agents, and attorneys, for the program/event that is being held on the date listed above at the facility listed above.

    In consideration for the City of Cocoa permitting the undersigned to choose not to obtain liability insurance, the undersigned hereby executes in favor of the City of Cocoa, Florida, and its officers, employees, agents, and attorneys, this Program/Event Indemnification and Hold Harmless Agreement, and agrees on his/her/its own behalf and on behalf of any and all derivative claimants and legal representatives of any and all types, nature, or relationship, to forever release, discharge, and hold harmless the City of Cocoa, and the officers, employees, agents, and attorneys thereof, and to indemnify the City of Cocoa and its officers, employees, agents, and attorneys thereof, in both their official and individual capacities, from any and all liability, claims, damages, expenses, including reasonable attorneys' fees and litigation costs through all appeals, resulting from or arising out of the use of the above-specified facility or facilities.

13. Signature*

    By typing my name in this form, I affirm the accuracy of the information provided in this agreement. I understand that this constitutes a legal signature and confirms that I agree to the above terms. I understand that I am electing not to provide the additional liability insurance coverage required by ordinance and by the event application. 

14. Date*
Leave This Blank:


16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit Submit and Print

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