Clean and Green Application Form

Activity Information
Name of Applicant:*
First Last
Phone of Applicant:*
Email of Applicant:*
Activity Name*
First Time Activity?*
- Yes
- No
Annual Activity?*
- Yes
- No
Number of Years Held
Anticipated Attendance*
Activity Date, Location(s), Time(s):
Please specify each Park/Location you are requesting to work at.
Please include setup and take down date(s) and Time(s) if different from Activity Dates.
Location
Activity Setup Date
MM slash DD slash YYYY
Time
: Hours
Minutes
AM/PM
Time
: Hours
Minutes
AM/PM
Activity Date
MM slash DD slash YYYY
Time
: Hours
Minutes
AM/PM
Time
: Hours
Minutes
AM/PM
Activity Take Down Date
MM slash DD slash YYYY
Time
: Hours
Minutes
AM/PM
Time
: Hours
Minutes
AM/PM
In the case of inclement weather will the Activity be cancelled or rescheduled (e.g. is this a ‘rain or shine’ event)?
Section 2: Activity Details and Safety Provisions
Description of Activities:
(e.g. what, where, how, particular focus for the activity)
Please identify the safety precautions that will be in place for the Activity:
Note: Noticing any hazards can be reported to the Community Partnership Liaison for Staff to address (e.g. traffic, contact with heavy objects, syringes, dead animals, etc.)
How will Activity Officials be Identified?
Food:
(e.g. pre-packaged snacks, bottled water, food vendors, etc.)
- Yes
- No
If yes, please describe:
Required: Haldimand Norfolk Health Unit Event Organizer Form and Food Provider Form which can be found at the following link: www.hnhu.org
First Aid:
Parking:
(where will participants be asked to park during the activity)
Other Details:
(please specify e.g. vehicle access in Park, closure of public amenities such as boat ramp, games, activities, raffles, lotteries, fund-raising, etc.)
Section 3: Supplies and Staff Support Requested
Clean-up Supplies:
(includes garbage and recycling bags, gloves, pickers, broom, dustpan, graffiti wipes, and sharpes container)
- Yes
- No
Preferred Location(s) for Waste Pick-up:
Consent*
By signing below I acknowledge that I have read the terms and conditions as outlined in the guidelines and in this application and fully disclosed all details and components of the proposed Activity.
1. I will abide by all terms, conditions and regulations as indicated on the applications required.
2. I am aware that failure to comply as outlined could lead to cancellation of this application and/or my Activity at any time.
Signature of Applicant:*
Date*
Month
Day
Year

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Clean and Green Application Form

Activity Information

Activity Date, Location(s), Time(s):

Section 2: Activity Details and Safety Provisions

Section 3: Supplies and Staff Support Requested

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