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2. Note: This form only needs to be completed for indoor events over 100 people or outdoor events over 200 people
4. Name of Responsible Party (Individual Name or Business Name)*
6. Responsible Party Address*
8. City*
9. State*
10. Zip*
12. Phone Number*
13. Email Address*
15. EVENT INFORMATION
17. Event Name or Function*
19. Event Address*
21. City*
22. State*
23. Zip*
25. Event Start and End Date and Time*
    Event Start and End Date and Time Start Date

    Event Start and End Date and Time Start Time

    —

    Event Start and End Date and Time End Date

    Event Start and End Date and Time End Time
    Include time for setup and cleanup
26. Expected Number of Attendees*
28. Expected Number of Event Staff*
29. Location on Premises*

    1. Indoors
    2. Outdoors
31. Please provide addition event details here, if needed
33. Attestation
    I am the Responsible Party for the event listed. I have reviewed all applicable New York State interim guidance for event activities and operations during the COVID 19 public health emergency, and I affirm that I have read and understand my obligation to operate this event in accordance with such guidance. I understand the event may be subject to inspection by Yates County Public Health to ensure compliance with all provisions of the guidance.
35. Attestation sign off

    1. By checking this box, I agree to the above statement
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field