Special Event Organizer Application | HealthUnit Haldimand-Norfolk

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Organizer Information

Event Organizer Contact Name*

Organization Holding Event*

Address*

Street Address City Province Postal Code

Email*

Event Information

On-Site Contact Name(s)*

Telephone Number – Primary*

Primary Telephone Number Type:*

Home

Work

Cell

Business

Telephone Number – Secondary*

Secondary Telephone Number Type:*

Home

Work

Cell

Business

Name of Event*

Event Location (including Street #, Street Name, and City)*

Start Date*

MM slash DD slash YYYY

End Date*

MM slash DD slash YYYY

Hours of Operation*

Type of Event*

Community Festival

Fundraiser

Tournament/Sports

Trade Show

Expected Attendance*

Is this an annual event?*

Yes

Water Supply

Water Supply Provided to Vendors*

Municipal Hook Up

Municipally Hauled

Vendors to bring their own

Commercially bottled

Other (please specify)

Please specify

Will a back-up supply of water be available?*

Yes

Power Supply

Will electricity be supplied to the vendors?*

Yes

Will back-up power be available?*

Yes

Sewage and Wastewater Disposal

Type of toilets supplied*

Fixed

Portable

Number of fixed toilets*

Number of portable toilets*

Type of hand wash sinks supplied*

Fixed

Portable

Number of fixed hand wash sinks*

Number of portable hand wash sinks*

Method of sewage disposal*

Municipal

Private/Septic

Method of wastewater disposal*

Holding tank

Grey water containers

Other (please specify)

Please Specify

Food Provider(s) List

Provide the information below for all food providers that will be participating in the event.

Food Provider List*

Name

Address

Phone and Fax

File

Max. file size: 2 MB.

If you would like to upload your list please do so by uploading a file from your computer.

Event Organizer Name*

Date*

MM slash DD slash YYYY

Site Plan

Please upload a sketch of the event area indicating the location of: 1. Food vendors 2. Toilets 3. Hand wash sinks 4. Garbage receptacles

File*

Max. file size: 2 MB.

By checking "I agree", the organizer certifies that they understand and will comply with the conditions outlined in this package. Any organizer found not to be compliant may be subject to the provisions of the Health Protection and Promotion Act, R.S.O. 1990 and/or applicable by-law.*

I agree