Block Party Request

2. 1. Date & Start & Finish Time*
   1. Date & Start & Finish Time Start Date

   1. Date & Start & Finish Time Start Time

   —

   1. Date & Start & Finish Time End Date

   1. Date & Start & Finish Time End Time
4. 2. Location*
6. 3. Approximately How Many People Will Be Attending?*
8. 4. What Type of Entertainment are you Providing, if any?*
10. 5. If Workload Allows, Would you Like Fire and/or Police Personnel to Stop and say Hello to any Children?*

    1. Police
    2. Fire
12. 6. Approximately how many Children Attending?
14. 7. Applicant's Name*
16. 8. Applicant's Email*
17. 9. Applicant's Phone*
19. 10. Applicant's Address*
21. Waiver*

    1. I have downloaded and read all of the "Guidelines" from this page and agree to abide by them as a condition of this request.
    2. I agree to hold harmless, the Village of Jackson, it's officials, officers, employees and agents from all suits, actions, damages or claims to which the village may be subjected of any kind or nature whatsoever resulting from, caused by, arising out of, or as a consequence of such temporary street closue and the activities permitted in connection therewith.
23. E-Signature

    Please Type Your Full Name Above as an Electronic Signature

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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field