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Home My WebLink AboutBrandon Dukes Memorial 5k Run Sot,9-5 sisoEpApr vrc` GAT Y ,F A n QQ "INN ~ SPECIAL EVENT APPLICATION uf Submittal of this application does not guarantee approval of the event. 0 This application must be completed in its entirety.Any applications not completed will be denied automatically. Before applying, please acknowledge that addendum will be utilized in instances where additional liability on behalf of the applicant may occur. Applications must include a detailed site plan which clearly shows all temporary structures including but not limited to tents, portable toilets,stages, bleachers,dumpsters, fencing, inftatables, etc.at the time of submission. It you are applying on behalf of a nonprofit. please provide proof of organization s nonprofit designation EVENT INFORMATION O AI�ON� ,,.-. `, Name of Event. Rf oG� c i c Type of Event S .. _k,._ Event Date(s): • 2-V-Ig i _ — Event Time: el Event Day 2: r Event Time:Event Day 3: Pt1Or 4' Event Time: Event Location: tifigA 1 kr k Alternate Date, Time and Location: _/ Will additional time be needed for set up/break down?(precise check) DYES D NOAIN ,t._ ,� Set up will begin on (date): • 23itt at (time) (/•• 4k `Break down will begin on (date) 2�a at (time): 10 kW\ Please provide a detailed description of your proposed event (be specs/Lc' (— 1APOUIS �t o-wr 6- k rwh Gi t4e._ (re{e �e ire 4.)0 _, 41) St) w\ 2/4trl'2- vAlriY‘ -CI.A.StPASedy g 144.-ov`. "Asjvi Givoki . 1\it V•111't tv4 e-- +kfroN S 11,1-44 )kii" (AA74-11 4-1A0d �`J N `^ c .- b, 1� WrtY s. Is this event open to the public? (please check) LyYES ❑NO Estimated attendance*: (9 0 tie-AY-C.- __ Estimated number of teams participating? (athletic tournament only) 0'�� -- 0•01\•Fees may be assessed during post event inspection if actual attendance exceeds above estimate 1 ORGANIZATION INFORMATION _Drganization producing the event: (please check) �]For Profit [elonprofit ❑Governmental ❑Neighborhood Association ❑Other: [(�� r� �� ,�Q Name: erk, o .9 CQi `, ( J 'y Street Address: Ust � . u City: 1\1 QA4-) A State: Zip Code: I �Q WebsitP 130 4451AaelA• ANA Phone: CD t V1V. 7.-191 Email: - ++� "A'7' �T ^. �s EM . r u11N` Social Media_ C`` a On-site Contact Name OW - J On-site Contact Phone: ?i l- qL)1' 277/1'1 l On-site Contact Email- •Ritietr1.4.0/O ' -• , in- (LMA. Phone number and/or email you want the public to contact for more information and to be listed online: 9t z-q 1-0. 1)-9 q 1 �t Pv,n,'6‘4.4.GOIAM.S-PJ9 TM, ( •caw+ \lumber of years this event has taken place in Jeffersonville: ^/2 Is this event produced in other areas? (please check) ❑YES [1lO If so, where? COST b FUNDING Ticket Prices(if applicable): &11 ( rAMAAW Adults 3l Children +el G IZ 9• Ivj' Seniors 131 How will ticket sale revenue be used? utnA.N . 1.o 4 3 bcJ Cl ado, i' g air If the proceeds of the everMre intended for an organization other than the applicant,please provide the following information: Benefit Organization: 144 of funds which will be donated: Contact Person: Contact Phone: Terms of the agreement: 2 ROAD CLOSURE —/ �n/ill your event require road closures? (please check) El YES L�'NO ,f yes, please describe the roads that would be closed and provide the opening/closing dates and times. Also, please attach map detailing closures and cross streets. Name of streets: Date/Time of Closure: Date/Time of Opening: PARKING �� Will you need any parking lots reserved for non-public use?(please check) ❑YES LKNO Will you be using areas for off-site parking? (please check) ❑YES L?NO TRAFFIC CONTROL ^// Will your event require traffic control? (please check) ❑YES LVNO ALCOHOL �,/ Will alcohol be served at your event? (please check) ❑YES Lj'NO FOOD _ " Will food be served at your event? (please check) 13cES 0 NO S n4a,S 4 V0414.1 If yes, will food be self-prepared? (please check) DYES 0 NO INFLATABLE ATTRACTIONS: (Please make sure to Include on site map) Will inflatable attractions (bounce houses, slides, games) be part of this event? (please check) ❑YES [ VO If yes, who will staff the attractions? 0 Vendor 0 Event Staff AMPLIFIED SOUND: -- // Will amplified sound be used at your event? (please check) rWES ❑NO If yes, what will be amplified (music, speeches, etc.)? (please check) 11; fES ❑NO S If yes, what time(s)will sound be amplified? (I , 'mk i"-' tits* If yes, what sound company will provide sound? slAAk 64 t� dwA— AUDIO/VISUAL EQUIPMENT: Please list any �A(/V equipment to be used at your event: N l 6r i"1 3 FENCING (Please make sure to include on site map)mill you be using temporary fencing for your event? (please check) ❑YES (240 If yes, what company wilt provide fencing? REFUSE AND RECYCLING (Please make sure to include on site map) Will you need refuse containers (dumpsters) for your event? (please check) ❑YES [ENO If yes, how many will be used? If yes,what company will provide refuse and recycling services? RESTROOMS (Please make sure to Include on site map) Will your event require temporary restrooms? (please check) ❑YES 2 NO If yes, how many? If yes,what company will provide restroom services? CLEAN-UP: Will you use a cleaning company for event clean-up? (please check) ❑YES [ 10 If yes, what company will provide cleaning service? ELECTRICITY: will you be using temporary electric (generator) at your event? (please check) ❑YES 110 If yes, what company will provide electric service? TENTS (Please make sure to include on site map) ��,�� Will you be using tents, stages,ticket booths, etc. at the event?(p)easecheck) I�dYES ❑NO If yes, will tents be larger than 150 square feet (larger tents require permit)? (please check)❑YES If yes, please indicate the number and size of tents and desribe how tents will be used: If yes for larger tents, what company will be providing tents? PROMOTING/ADVERTISING: What type of promotion/advertising do you have planned for your event? "7-4CL ee" .r( ove4 tm),,A4/. ,04,44.4164ArkiKA-v6.,' SIGN AND RETURN this completed application with supporting documents to the Jeffersonville Parks Department, Attn: City Events Planning Board. email. parksinfo@cityofjeff.net Mail: 500 Quartermaster Court Jeffersonville, IN 47130 Applicant agrees that the contents of the application are complete, true and accurate to the best of their knowledge, info Lion and belief, and agrees to ensure compliance with the policies set by the City Events Planning Bo rd. ?)" la- '2'3 Si nature of Applicant Date *Upon approval by the City Events Planning Board, applicant will be required to pay the Special Event Permit Fee determined by the Board.This fee is usually set at $150 per application, but may be increased depending on use of city services, risk assessment or other factors. **A certificate of insurance is required for all events, with minimum coverage of$1,000,000 liability.The certificate must list the City of Jeffersonville as additional insured, and must be submitted to the Parks Department at least 10 days prior to the event date. pr;t'„� This section to be completed by City Events Planning Board /'816\ PERMIT FEE ~r l l' $ Receipt# APPROVED B Date Police: 0.1 q 5eleY Fire: 1/s/aA`� Street: 11�' I -5- 2 3 Parks: /ipt; 9-5— Safety: 4115- rL3 Director: (-)04)&(\,:rot _ 046lZ3 QPv.-) a kk3 5