Village of Jackson Block Party & Street Closure Request Form

Date*

Start & Finish Time*

Location*

Approximately how many people will be attending?*

What type of entertainment are you providing, if any?*

If their workload permits, would you like fire and/or police personnel to stop and say hello to any children?
FirePolice

Approximately how many children?*

Applicant's Name*

Applicant's Email*

Applicant's Phone*

Applicant's Address*

I have downloaded and read all of the "Guidelines" from this page and agree to abide by them as a condition of this request.

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.

Please type your full name below as an electronic signature.