2. Washington County COVID-19 Large Gathering Event Notification Form
4. Name of the Event*
6. Date of Event*
   Date of Event
7. Event Time (Start to Finish)*
   Event Time (Start to Finish) Start Time

   —

   Event Time (Start to Finish) End Time
9. Event Location/Facility Name*
11. Room Listed Capacity (at 100%)*
12. Room Calculated Capacity (at 50%)*
14. Event Location Additional Details*
16. Location Address*
17. Location Town / Village*
    -- Select One --ArgyleCambridgeDresdenEastonFort AnnFort EdwardGranvilleGreenwichHamptonHartfordHebronHudson FallsJacksonKingsburyPutnamSalemWhite CreekWhitehall
19. Event Contact / Responsible Parties Name*
20. Event Contact / Responsible Parties Phone #*
22. Event Contact / Responsible Parties Email Address*
24. **Food Service Facilities must have NY Forward Safety Plan completed and available for review**
26. Expected # of Attendees*
27. Expected # of Event Staff*
29. *All guests must be required to sign in, and provide full name, date of birth, address, email and phone #’s. *Table seating chart (if applicable) must be retained. Who will maintain guest sign in (and table seating chart) for 28 days in the event contact tracing is required.
31. The information below is provided as a reminder of some of the requirements. Please refer to the NYS Forward Phase 3 “Interim Guidance For Food Services During the COVID-19 Public Health Emergency “ for full explanation of requirements.
32. NYS DOH Latest Guidance Document
    NYS DOH Latest Guidance Document
34. The responsible party submitting this form must affirm below that all applicable current NYS COVID-19 Executive Orders and Guidance will be followed. Responsible Party I am the responsible party for the business, organization or 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 that my event may be subject to inspection by the Washington County Public Health to ensure compliance with all provisions of the guidance.
36. By checking this box, I (the Responsible Party) agree to the above statement.*

    1. I AGREE
37. Date Affirmed*
    Date Affirmed
39. Responsible Party (e-Signature - Type Full Name)*
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field